Transcript Behavioral Health Rehabilitation

Behavioral Health
Rehabilitation
Access to Counseling
Services
1
Disclaimer
The following information is not sanctioned by any state or federal
agency, you as a licensed or certified and credentialed clinician are
ethically and legally responsible for following state/federal regulations
in the services you provide.
Notable Definitions
"BH" means behavioral health, which relates to mental,
substance abuse, addictions, gambling, and other diagnosis
and treatment.
"BHRS" means Behavioral Health Rehabilitation Specialist.
"CM" means case management.
"LBHP" means a Licensed Behavioral Health Professional.
"Objectives" means a specific statement of planned
accomplishments or results that are specific, measurable,
attainable, realistic, and time-limited.
"Trauma informed" means the recognition and responsiveness
to the presence of the effects of past and current traumatic
experiences in the lives of members.
Behavioral Health
Rehabilitation Specialist

BA or MA degree from an accredited college/univ;
AND*
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Completion of the ODMHSAS BHRS training; OR
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Cert. Psychiatric Rehab Practitioner credential; OR
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Certification as an Alcohol and Drug Counselor; OR
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Licensed as a RN withDMHSAS BHRS credential; OR
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BHRS prior to 7/1/10 withDMHSAS credential on file.
Behavioral Health
Rehabilitation Specialist-cont’d.
 A BHRS, CADC, or LBHP may perform BHR, following a treatment
curriculum approved by a LBHP.
 Staff must be appropriately trained in a recognized
behavioral/management intervention program such as MANDT,
MAB, CAPE or Trauma-Informed Method.
 Other requirements are based upon the agency’s accrediting body.
Treatment Team Levels
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Agency Clinical Director - determines the scope of
practice/directions for treatment on cases
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Licensed Behavioral Health Professionals - assessment,
treatment plan oversight, psychotherapeutic treatment
services, oversight of Rehab and Case Managers
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BHRSs - focused on skills development following curriculum &
treatment plan approved by the LBHP
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Case Managers - focused on finding and linking the
individual/family with needed resources, and advocating for
them (overseen by the LBHP)
Psycho-Social Rehab
Services - (PSR)
 PSR is the process of restoring community functioning and well-being of an
individual who has a psychiatric and/or substance abuse disorder.
Rehabilitation work seeks to effect changes in a person’s environment and in a
person’s ability to deal with his/her environment, so as to facilitate improvement
in symptoms or personal distress.
 FOCUS: develop an individuals skills in areas of living life in a healthy and
functional level that increases one’s satisfaction with life!
The Role of the Rehab
Worker
 Teach skills that complement ideas and concepts
processed in therapy.
 Provide input goals and objectives for the Treatment Plan.
 Help Treatment Team document progress toward identified
goals and objectives.
 Communicate client needs to treatment team leader.
 Promote reward programs that have been set-up with
treatment team.
PSR - 8 main Areas
1. Psychiatric
2. Social
3. Vocational/Educational
4. Daily Living Skills
5. Financial
6. Community/Legal
7. Health/Medical
8. Housing
Policies, Rules and
Rates
Medicaid Policy OAC 317:30-5-240 - 249
Outpatient BH Services: are covered when provided under a full
BioPsychoSocial Assessment and Individualized Treatment Plan
conducted by a LBHP. TheTreatment Plan is developed to treat the
identified mental health and/or substance abuse disorder(s), with the
goal of improvement of functioning, independence, and well-being of
the member. The member must be able to actively participate, have
sufficient cognitive abilities, communication skills, and short term
memory to benefit from treatment.
Individual Rehab

Performed face to face
with only the client and
the BHRS.

Sessions may include a
client’s family/support
system in order to focus
on the individuals
goals/objectives.
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Ages 6 and up
Group Rehab

Performed face to face with only the BHRS and a
group of clients.
Staffing Ratios:
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1 BHRS to 14 adults (18-up)
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1 BHRS to 8 children (6-17)
PSR Policy
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Community or Office Based
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Travel time to and from PSR is NOT reimbursable.
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No-show or cancelled appointments cannot be billed.
If a person uses SoonerRide (SR):
Individual PSR, SR is covered
Group PSR, SR is NOT-covered, unless the client has special
transportation needs for wheelchair, etc.
PSR Policy

Breaks, meals and times when the client is unable/unwilling to
participate are NOT compensable, & must be deducted from billed
time.
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CMS federal 8-min rule: when you do 8 minutes minimum, then you
round up to a 15 min unit.
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If you do less than 8 min, then you do not bill that unit.
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The BHRS must be present interacting, teaching, and/or supporting
the learning objectives of the member for the entire claimed time.
Daily Limits
Individual PSR
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6 units/1.5 hours per day maximum allowed
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Clinical standard is 1 hour
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Time must be age/developmentally appropriate
Group PSR
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24 units/6 hrs adults, 16 units/4 hrs children
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Group clinical standard is 1 - 1.5 hrs per subject/topic
PSR Rate Schedule
Individual PSR
$11.79 per 15 min
Group PSR
Adult (18 and over)—$2.72 per 15 min
Children (0-17) )—$3.89 per 15 min
Areas of Lawsuit Risk

Being assigned alone to a case without the oversight of a LBHP
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Allowing a client to think that you are their therapist.
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Attending to crisis situations that are non-medical emergencies.
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Having contact with clients outside of sessions.
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Crossing the boundary between Rehab and Therapy, or Case Management.
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Not carrying professional liability insurance
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Being assigned to the same caseload as a family member or friend
Areas of Lawsuit Risk
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Rendering services to children at inappropriate times of the day.
Transporting clients without proper insurance coverage and permission
signatures.
Billing for individual services when group services were rendered.
Not accurately documenting the time-frame within which services were
rendered.
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Assuming responsibility for the client.
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Failing to report abuse and fraud.
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Outings which have little to do with teaching skills.
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Promising gifts/rewards in exchange for attendance in sessions.
BHRS Safety Rules
Take your safety and your
clients’ safety very seriously.
Follow all state laws and rules.
Do not ever feel that you have
to enter or stay in a situation
that you do not feel safe, leave
immediately, contact your
employer and reschedule your
appointment at a safe location.
Familiarize yourself with our
safety manual.
Trauma-Informed Care
Trauma-informed care is both a philosophy and a way of providing
services based on compelling research over the past 20 years. The
research indicates the exposure to trauma is not only dramatically
more prevalent than previously known, but also closely linked to
many detrimental medical, psychological and social outcomes
throughout an individual's lifespan.
Exposure to adverse experiences is especially harmful during
childhood when the brain is in a rapid stage of development.
Immediate behavioral health interventions offer real hope for
minimizing negative consequences, but even in situations where the
traumatic experiences occurred long ago, new and evidence-based
practices can be helpful.
The Adverse Childhood Experiences Study
What does it mean to be a
Trauma-Informed Care Agency?
In addition to evidence-based practices, a trauma-informed agency
examines every aspect of their management and service delivery
systems to ensure they support healing. This includes having an
appreciation for the high prevalence of traumatic experiences for all
people in our society and particularly in persons who seek and/or
receive behavioral health treatment.
What Does It Mean to Create a Culture of
Trauma-Informed Care?
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Developing a culture of physical and emotional safety for everyone; clients, their
families and staff alike.
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Having the belief and understanding that everyone is born with the capacity for
progressive development, but that this capacity can be derailed by
overwhelming life stressors and traumatic experiences. As a result of these
events, individuals and systems may develop maladaptive coping skills that
make sense in the context of the history. This is true for clients, their family
members, as well as staff members at all levels of an agency.
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Surfacing and resolving conflicts
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Promoting and valuing honest communication.
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Respecting everyone's feelings and perspectives, even when they differ
What Does It Mean to Create a Culture of
Trauma-Informed Care?- cont’d.
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Maintaining and supporting emotional regulation for self and others.
Extending kindness and compassion while maintaining healthy
boundaries.
Working from a strength-based approach that honors the belief that
everyone is doing the best he or she knows how.
Having and cultivating a fun attitude with one another about whatever has
to be done, as well as doing whatever has to be done with a sense of joy!
Using group process, group problem solving, and creative problemsolving, whenever feasible, for resolution of shared problems.
What is Client-Centered Care?
Client-centered care is an innovative approach to the planning,
delivery, and evaluation of care that is grounded in mutually
beneficial partnerships among clients, families, and providers.
Client-centered care applies to people of all ages, and it may
be practiced in any setting.
The Core Concepts of Client-Centered Care
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Dignity and Respect— Practitioners listen to and honor client and family
perspectives and choices. Client and family knowledge, values, beliefs and
cultural backgrounds are incorporated into the planning and delivery of care.
Information Sharing— Practitioners communicate and share complete and
unbiased information with clients and families in ways that are affirming and
useful. Clients and families receive timely, complete, and accurate information in
order to effectively participate in care and decision-making.
Participation— Clients and families are encouraged and supported in
participating in care and decision-making at the level they choose.
Collaboration— Clients and families are also included on an agency-wide basis.
Leaders collaborate with clients and families in policy and program development,
implementation, and evaluation; in facility design; and in professional education,
as well as in the delivery of care.
Do you exhibit these
competencies?
1. Listens to all symptoms/problems before making moving toward
goals and solutions.
2. Is knowledgeable about the person's condition; past and current
status.
3. Is very knowledgeable about curricula, procedural changes from
their agencies, and/or licensing bodies.
4. Encourages clients and family members to ask questions and
participate in the care experience.
5. Gives options for solving problems and suggests ways in which
client and family member can participate in care.
Do you exhibit these competencies?cont’d.
1. Collaborates with client and family member in seeking additional
solutions.
2. Volunteers information about agencies that provide additional
services and knows how to access those services.
3. Uses familiar terminology or carefully defines new terms; checks
that client and family member understand.
4. Takes time and does not seem rushed.
5. Follows through on care and outcomes.
Documenting Progress
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Through your work as a BHRS, you will are required to thoroughly
document each visit with each client.
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Keep in mind that this document is a part of the ongoing
assessment and re-assessment of the client’s strengths, needs,
abilities, preferences, and liabilities.
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It is very important that your progress notes thoroughly document
what took place during the session and is directly related to the
goals and objectives that are stated in the treatment plan.
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You must state clearly in your note which treatment plan goal(s) and
objective(s) were addressed during your session with them.
Cycle of Client Care
The Context of Rehab
Work
 In order to keep the lines between rehabilitation, case
management and therapy separate, it is easiest to think of a
rehabilitation worker as a teacher.
 Using this context, a teacher would not seek out resources for
their student, most likely they would refer them to the school
counselor or local case manager.
 Using this context, a teacher would not talk to a student about
their feelings about a particular event, instead they would send
the student to see the school counselor.
The Role of Active
Learning
Active Learning- a concept in which people participate in their own
learning process by involving them in some type of activity where they
physically become part of the lesson, i.e. learning by doing.
Methods of active learning- role-playing, simulations, debates,
demonstrations, problem solving initiatives, skits, discussions, games,
etc.
 Based on process rather than outcome
 Uses both left and right brain.
–Adapted from Activities That Teach by Tom Jackson
The Process of Active
Learning
 General Concept presented to individual/group
 Specific information about topic given to individual/group
 Activity performed
 Discussion about actions/consequences during activity
 General principals of topic/activity discussed
 Specific skills/techniques are discussed along with application to real
world situations
 Both left and right brain record event for future use
The Process of Active
Learning
 Recap learned skills and techniques and have client write
their own note, or journal things to share with therapist
 Client uses skills/techniques in future events to create
change
 Client process the use of skills/techniques and the event with
therapist
-Adapted from Activities That Teach by Tom Jackson
The Learning
Environment
Create a physically and emotionally safe environment. Confidentiality
should be of utmost importance in community settings. Group sessions
should be governed by rules that they group creates.
 Establish a “freeze” command.
 Remove/time out participants who refuse to cooperate, report this to
their therapist.
 Keep directions short and to the point.
 If possible, demonstrate what you want done.
 Prepare for imperfect experiences.
Managing Communication
 Focus on only the task at hand and the skills/techniques being
learned.
 Avoid questions such as, “What feelings do you have about…”
 Use questions such as, “Can you give an example of…,” “What
part of the activity made you think of…,” “What else can you
add…,” “How could we change…,” “Who has a different
viewpoint,” etc.
Managing Communicationcont’d.
 Redirect participants that feel the need to process their feelings by
using the following:
 “That’s very important information that needs to be shared
with..(Therapist/Case Manger).”
 Refocus back to the task at hand by asking if there is a skill that can
be used to prevent X occurring next time.
 Clients who frequently want to process during rehab may need to
keep a journal and be allowed to record feelings to discuss with their
therapist at a later time.
Qualities of a Great Behavioral Health
Rehabilitation Specialist
Passion to Teach
You need passion to teach others in order to be a good BHRS. Know your subject
and show the clients that you are passionate about that subject and they will be
willing to learn even more.
Patience
Patience is necessary for a BHRS. You are dealing with people for extended
periods of time, so you will have to be quiet and calm with the clients.
Good Communication
You want to be both a good listener and speaker. Getting people to answer
questions will involve getting their attention and making them comfortable enough
to speak up. You will lose their attention by being dull and speaking in a monotone
voice.
Qualities of a Great Behavioral Health
Rehabilitation Specialist- cont’d.
Problem Solver
Unique problems arise in the field. You will need to be a problem solver and able to think on your
feet when surprises occur in your sessions. You need to know when to step back and staff a
situation.
Supportive
Your clients need to know that you are there for them if they need help. Let them know they can
come to you for help while, at the same time, practice healthy boundaries.
Able to Interact With all Ages
If you are assigned to work with families, you need to interact with not only the children, but their
parents and other clinicians. Make sure you are comfortable with all age groups.
Leadership
You are in a leadership role, and your clients see how you behave. Always be aware of what you
say or do (model desired behaviors) because clients are watching and learning from you.
Psychiatric
Teaching Symptom Management
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Depression
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Anxiety & panic attacks
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ADHD
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Anger
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Trauma
Vocational/Educational
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NOT-Tutoring
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Coping Skills
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Job Application/Résumé Development
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Interviewing Skills
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Motivation
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Customer Service
Social
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Relationships
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Family
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Boundaries
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Communications
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Community Integration
Daily Living Skills
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Hygiene Skills
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Food Planning/Preparation
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Cleaning/Housekeeping Skills
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Safety Knowledge
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Scheduling/Time Management
Community/Legal
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Accessing Resources (not to be confused with Case Management)
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Being an Active Part of one’s community
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Presentation skills
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Setting up Supports
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Taking Charge of Records
Financial
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Budgeting
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Bill Paying/Utilities
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Setting up a Bank Account
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Tax Preparation
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Saving
Health/Medical
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Nutrition
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Exercise
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Meditation/Relaxation
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Medical/Psych Appointment Management
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Symptom Management
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Learning how to keep Schedules/Logs
Housing - acquiring & maintaining
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Housing
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Furniture
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Safety
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Appliances
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Maintenance
Case Management
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Do Case Management to assist a client in accessing needed
resources in their community to live independently.
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Don’t perform CM and bill it as PSR!
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Go get your CM certification so you can bill for this!!
Progress Notes (PNs)
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Focus—What objective(s) were worked on in session? What skills
were taught/learned/practiced?
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Intervention—What specific techniques/behaviors/suggestions did
you use to promote change?
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Response—What did the client report? How did the client respond
to the intervention(s)? What did they practice?
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Plan—What is the client going to work on between now and next
session?
Appropriate Terms for BHRS
Use this…
Instead of this…

“teaching”
 “assessing”
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“practicing”

“processing feelings”
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“role playing”

“tutoring”
“monitoring the client’s progress
on their Tx Plan goals”

“mentoring "or “coaching”

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“coordinating with the therapist
on client care”

“parent skills training” (unless the
parent is the client)
Required Elements (PNs)
317:30-5-248 Documentation of records
[Revised 07-01-10]
Date; Person(s) to whom services were rendered; Start and stop time
for each timed treatment session or service;
Original signature of the service provider; Credentials of
therapist/service provider;
Specific service plan need(s), goals and/or objectives addressed;
Services provided to address need(s), goals and/or objectives;
Progress or barriers to progress made in treatment as it relates to the
goals and/or objectives;
Member (and family, when applicable) response to the session or
intervention; Any new need(s), goals and/or objectives identified during
the session or service.
In addition to the items listed above :
(B) a list/log/sign in sheet of participants for each Group rehabilitative
or psychotherapy session and facilitating BHRS, LBHP, or CADC must
be maintained; and
(6) Concurrent documentation between the clinician and member can
be billed as part of the treatment session time, but must be documented
clearly in the progress notes and signed by the member (or note if the
member is unable/refuses to sign).
Do’s & DON’Ts
 Do what is clinically right for the client.
 Don’t do the daily maximum allowed hours just because the policy
says you can.
 Don’t do the daily maximum in order to make more money.
 Don’t work without the supervision/consultation of the LBHP or
Clinical Director on cases.
Required Elements (PNs)cont’d.
Progress notes for intensive outpatient mental health, substance
abuse or integrated programs may be in the form of daily summary or
weekly summary notes and must include the following:
 Curriculum sessions attended each day and/or dates attending
during the week;
 Start and stop times for each day attended and the physical
location in which the service was rendered;
 Specific goal(s) and objectives addressed during the week;
Required Elements (PNs)cont’d.
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Type of Skills Training provided each day and/or during the
week including the specific curriculum used;
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Member satisfaction with staff intervention(s);
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Progress, or barrier to, made towards goals, objectives;
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New goal(s) or objective(s) identified;
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Signature of the BHRS; and Credentials of the BHRS.
Do’s & DON’Ts –
cont’d.
 Do take a child to an activity, and bill only the face to face time that
you spend teaching a skill or observing the client practicing that skill.
 Don’t take a child to an activity and bill for the whole time.
 Don’t take a group of children to an activity, go off with one child to
do Individual Rehab and leave the rest unattended.
 Don’t take any child that is not an enrolled client on a rehab outing.
 Don’t treat a child under age 6.
Do’s & DON’Ts-
cont’d.
 Do sit in a child’s class to observe, then do some instruction with the
child when allowable, focused on what will help them to maintain
better in school and with their peers. (The observation time is not
billable)
 Don’t go sit in a child’s class and bill the whole time.
 Most school systems do not allow for PSR to be billed during school
hours.
BHRS Resources
State & Federal Authorities - www.okhca.org
Policies, Payment Rates, and Medicaid Fraud Reporting
Websites
Center for Psychosocial Rehab - www.cpr.org
Liability Insurance - www.hpso.com, www.cphins.com, etc.
THE END