Transcript Collaborative Best Practice Documentation

NYS Case Management Coalition Conference
May 2, 2012
Presented by
Valerie Way, LCSW-R
New York Care Coordination Program
Phase I
Timeline for Transformation
• 2002 - Laying the foundation for transformation
• Collaborative processes, care coordination, person-centered
practices, recovery focus, promotion of peer services & supports,
physical health awareness, data driven
• 2009 - Partnership with Beacon Health Strategies, LLC
• Managed care readiness
Phase II
• Complex Care Management Program
• 2011 - RBHO’s and Health Homes
• Award of the Western Region Behavioral Health Organization
Phase III • Health Home Application
The emerging health care
environment is focused on…
The
whole
person
Recovery Focused,
Person-Centered Practices
Greater
Accountability
f0r Outcomes
Engaged
Partnerships
with
Consumers
Integrated
Physical/
Behavioral
Health Care
The Successful Care Manager
How do recovery plans fit in?
 Used as a meaningful tool for providers,
consumers, payers and oversight authorities
 Supports integrated and coordinated care
 Supports family/person-centered
approaches
 Clarifies medical necessity in
documentation
 Promotes resiliency and recovery
Serving Two Masters
Understanding
Regulation
Person-centered
• Recovery
• Community
integration
• Core gifts
• Partnering
• Supports self-direction
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Medical necessity
Diagnosis
Documentation
Compliance
Billing codes
Outcomes and
Goals
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“It is very important and necessary
for individuals pursuing mental
health and addiction recovery to
design their own road maps. This
book will assist providers in
understanding their role in the
journey of developing and
facilitating an individuals' road
map through person-centered
planning. “
-Wilma Townsend
recoveryskillbuilder.com
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“This toolkit can be useful for anyone –
regardless of whether they have a
psychiatric condition or an addiction.
Everyone needs help at times setting
goals, and figuring out what they want.
This toolkit has some specific parts that
are helpful to people with a mental illness
or addiction, but could be really used by
anyone.”
-Janis Tondora
-Rebecca Miller
-Kimberly Guy
-Stephanie Lanteri
Yale Program for Recovery
and Community Health
© 2009
Building a Plan
*Adams & Grieder
Outcomes
Services
Objectives
Strengths/Barriers
Goals
Prioritization
Understanding
Assessment
Request for services
Vital Competencies for
Developing Recovery Plans
1.
Person-Centered Practices
2. Medical Necessity
3. Phase of Change/Phase of Recovery
4. Recovery Plan Components (goal, objectives,
interventions, etc.)
1. Person-Centered Practices
 See the individual as the expert in their life
 Include significant others/key collaterals
 Identify strengths, capabilities, interests,
preferences, needs, hopes and dreams
 Are culturally and linguistically competent
 Provide a systematic way to align resources
and supports with the person’s goals
Person-Centered Practices
“Important To”
 Define what is important
to the person
 Use quotes whenever
possible so the
documentation clearly
reflects their input
 Define desired changes
in terms of specific,
observable behaviors
“Important For”
 Address issues of health
or safety
 Define objectives the
person needs to achieve
to be a valued
community member
 Addresses willingness
and motivation to invest
in recovery
2. Medical Necessity
Definition: “The clear demonstration that there is a
legitimate clinical need and that the services provided
are an appropriate response.” - Adams and Grieder,
Treatment Planning for Person- Centered Care, 2005
 Symptoms support diagnosis and lead to functional
deficits/barriers in the person’s life.
 Treatment/interventions target the functional deficits
to reduce or eliminate the impact of the diagnoses.
5 Elements of Medical Necessity
1. Indicated: There is a diagnosis to treat.
2. Appropriate: There is a match between
the interventions provided and the
individual’s need.
3. Efficacious: The intervention has been
proven to work.
4. Effective: The intervention IS working.
5. Efficient: Time and resource sensitive
3. Models of Change/Recovery
Ohio
Village
Prochaska &
DiClemente
Stage of
Treatment
Engagement
Treatment Focus
Dependent
unaware
High risk/
Unidentified or
unengaged
Pre-contemplation
•Outreach
Dependent
Aware
Poorly coping/
Engaged/
But not self-directed
Contemplation/
Preparation
Persuasion
Independent
Aware
Coping/
Self-responsible
Action
Active
Treatment
•Counseling
Interdependent
aware
Graduated or
Discharged
Maintenance
Relapse
Prevention
•Prevention
•Practical
help
•Crisis intervention
•Relationship building
•Psycho-education
•Set
goals
•Build awareness
•Skills
training
•Self-help groups
plan
•Skills training
•Expand recovery
Stages of Change*
 Pre-contemplation: Unaware of the problem or do not want to
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fix it.
Contemplation: Beginning to think change might be a good
idea.
Preparation: Readying themselves to do things differently
regarding the problem.
Active Change: Doing things differently and is actively working
to fix the problem.
Maintaining Change: Made significant improvements and
wants to keep things from going back to the way they were
previously.
Relapse: Things have slipped back to the way they were before
and the individual needs to reinvest in the process of change.
(Relapse may or may not be a phase in the process.)
*Based on the work of Prochaska and DiClemente
4. Components of the Plan
 Goal
 Strengths related to the Goal
 Barriers related to the Goal
 Objectives
 Interventions/Services/Supports
 Discharge Criteria
Key Points about Goals
 Goals express the hopes and
dreams of the individual.
 Goals identify the hoped-for
destination to be arrived at
through the services provided.
 Goal development is an
essential part of engagement
and creating a collaborative
working relationship.
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Common Mistakes
 Goals
 Not global
 Not directed towards recovery
 Not responsive to need
 Not strengths based
 Too many
 Not in the person’s own words
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Examples of Goals
Tom will have a 50% reduction of depression symptoms
“I will obtain LPN license.”
John will report satisfactory relationships with family members
“I want to have better relations with my parents”
“ I want to continue drinking without getting suicidal”
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Identify Strengths
• Abilities, Talents, Competencies, Accomplishments
• Values and Traditions
• Interests, Hopes, Dreams, Aspirations and Motivation
• Resources and Assets
• Unique individual attributes (physical, psychological, performance
capacities, sense of humor, etc)
• Circumstances at home, school, work, or community that have
worked well in the past
• Family members, relatives, friends, other “natural supports” in the
community
• Cultural Influences
• Previous successful experiences
*Adams/Grieder
Identify Barriers
What keeps the person from their goals?
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Environmental
Individual qualities
Areas needed for skill development
Intrusive or burdensome symptoms
Lack of resources
Self defeating strategies/interests
Cultural factors
Threats to basic health and safety
Substance use
*Adams/Grieder
What do Objectives do?
 Take into account the
culture of person served
(what’s relevant).
 Divide larger goals into
manageable units of
completion.
 Provide time frames for
assessing progress.
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Key Points about Objectives
 In contrast to long-term goals, objectives must be stated in behaviorally
measurable language (action words).
 They are time-limited and it must be clear when the client has achieved the
established objectives.
 Objectives should be responsive to diagnosis, stage of recovery, age,
development and culture.
 Objectives should capture the positive alternative to the current needs and
challenges and work to remove barriers, build on strengths and address
cultural issues.
 Each objective should be developed as a step toward attaining the broad goal;
they can be changed and updated as the plan is reviewed. Maximum of 2-3 per
goal is recommended.
 When all the necessary objectives have been achieved, the individual should
have accomplished the goal successfully.
How to write Objectives
RUMBA:
Realistic, Understandable, Measurable, Behavioral, Achievable
Example
Template
 Subject
 Verb/Action Word
 What
 When will it be done/timeframe?
 How will it be measured?
 Jason
 will use
 any of his three coping techniques
to address anger with parents
 at least once a week over the next
month
 as measured by family report log.
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Common Mistakes
Objectives
 Don’t support the goal
 Not measurable or behavioral
 Interventions become objectives
 Not time framed
 Too many simultaneous
objectives
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Examples of Objectives
In the next 6 months, Sam will successfully use 3-4 identified coping
strategies to manage his feelings of anger as tracked in his journal.
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In the next 3 months, Tammy will utilize a WRAP plan to successfully
identify and plan for early warning signs of suicidal thoughts.
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Tom will identify unhappy feelings related to life circumstances which will
not be fixed by medications.
Within the next 6 months, Doug will self report being free from the
distraction of symptoms of auditory and visual hallucinations and poor
concentration for a period of 1 month.
John will use his humor to improve relations with his family.
Key Points about Interventions
 Interventions are the things in our “tool box”
 Interventions reflect what specific action clients, clinicians, family
members, natural supports, etc. will take to address target objectives.
 Interventions describe medical necessity. This is where you identify
what service is being provided (things that we want to get paid for).
 Interventions must specify: provider name and discipline, modality,
frequency/intensity and duration, purpose/intent/impact.
 There should be at least one intervention for every objective. Consider
biological, psychological and social interventions as well as natural
support systems.
 If the objective is not accomplished after the first intervention, then
new interventions should be added to the plan. Keep in mind
readiness/interest level in making change.
The 5 W’s of Interventions
 Who: Which member of the team or
support system will provide it.
 What: Specifically what will be
provided/done.
 When: How often, how much time
and what is the duration.
 Where: Identify the location of the
delivery.
 Why: Identify the purpose of doing
the action. Link the intervention
back to the desired outcome.
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Common Mistakes
Interventions
 Purpose/why not included
 Frequency, intensity, and duration
not documented
 Too few
 Don’t reflect multidisciplinary activity
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Examples of Interventions
Tom will attend weekly psycho-education group.
In the next month, Doug will gather information
regarding 1-2 educational programs for obtaining his
LPN.
John and his parents will spend 30 minutes each week
for the next three months doing a family activity
together to increase family relations.
Sam will meet with counselor each week and attend
group 3 days a week.
Therapist, Patti Dropp, CASAC will meet with Tammy
once a week for 45 minutes over the next two months to
discuss daily activity logs which monitor alcohol use and
suicidal thoughts.
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Putting it All Together
Goal:
 Is it in the person’s words?
Strengths and Barriers:
 Do they relate to identified goal?
 Are there barriers related to behavioral health symptoms?
Discharge Criteria:
 Does it clearly reflect when the person has completed this episode of
care?
Objectives:
 Do they meet RUMBA?
 Do they reflect stage of change?
Interventions:
 Do they meet the 5 W’s?
 Do they reflect where the person is at with their readiness to make
change?