Common Biopsychosocial Issues and ways to Improve Documentation

1. Common Biopsychosocial Issues and ways to Improve Documentation

2. Corrections If you have submitted any documentation during your time employed at Quest, you have probably been asked to make corrections in some way, shape or form. We understand that getting documentations back with corrections request can be frustrating and time consuming. Please know that we only ask for corrections that are necessary for our documentation to pass an audit and we are here to help in anyway possible if you have concerns or questions. To try and make the process a little smoother, this monthly training is devoted to shedding light on common problems on BPS forms that cause the document to be sent back for corrections.

3. Recent DMH Audit We were recently audited by DMH and they requested we start adding the following info to all BPS forms: • Spirituality info • What religion, if any, does the client identify with. What type of church does the client attend? How important is faith/religion in every day life? Do they pray, sing worship songs, attend mass, take communion, participate in Ramada celebrations, tithe, burn incenses for spiritual reasons, etc.? • If the client does not have any spiritual activities, beliefs, etc., please check the appropriate boxes on the BPS. • Cultural info • Please state client's age, race, gender, SES, urban or rural identification, political affiliation, religious affiliation and if client participates in any cultural activities such as baptisms, pow-wows, Kwanzaa, etc.

4. Recent DMH Audit • Sexuality • If client is child or other individual with no sexual history, please state "client has not engaged in sexual activities.”. • DMH wants to see info about past experiences, thoughts on sexual experiences, concerns, preferences, etc. If the client does not want to discuss this info, that is completely understandable and acceptable, but you need to state on the BPS that “client does not wish to discuss sexual information at this time.”.

5. Recent DMH Audit • Preference for treatment • Please state who will be providing the services and the frequency of the services the client would like to receive. • Please state if the client has any preference in age, race, religion or gender of the MHP. If none were reported please note this in this section. Ex. “client reported having no preference in age, race, religion or gender of the MHP.” • Discharge criteria • Client reports- what does the client want to get out of therapy? What do they want to accomplish? • Please list clinical discharge criteria in addition to client report. Ex. “client will reduce defiance at home, client will report feeling safe and comfortable at home most of the time, client will reduce anxiety, client will remain sober for 6 weeks.”

6. Other Common BPS Concerns

7. Leaving Blanks • Even if the info doesn’t apply to your client, please list none or N/A in the box. When the forms are audited, it is assumed that blanks are areas that the LBHP skipped over in the assessment. If you fill the blanks in with none or N/A it shows that you did assess for the info with the client. • Some areas are overlooked because the text boxes are small- Ex. - county of residence, annual income, GAF score, treatment history, family substance abuse history, etc. Please watch for these areas.

8. Copying and pasting from client to client • The info in each BPS needs to be individuated to each client. No two clients are exactly the same and should present with different behaviors, cognitions, emotions, etc. • Some clients that are within the same family/home may have similar history and current circumstances. Info about family history can be the same on the BPS, info about current concerns in the home can be the same, info about family financial stressors can be the same but everything else needs to be specific to the individual client. In domain 5 (family), while some info can be similar to the other clients in the home, you still need to list information about how the client specifically functions in the home or copes with stressors in the home.

9. Issues with Diagnoses • Not listing a diagnosis from the DSM or ICD-9 • All diagnoses need to be clinical diagnosis. Anxiety, depression, anger, defiance, mood swings, etc., are not diagnoses found in the DSM and are not accepted by the State. • Listing a diagnosis that is not supported with info • Every diagnosis listed needs to be justified. It needs to be apparent that the client meets criteria for the given diagnosis. The summary of assessment is the best section to list supporting details for the diagnosis. • Please check the DSM criteria for each diagnosis before listing on the BPS. Please list specifiers when appropriate. It is easy to get in the habit of listing NOS but that is not always appropriate.

10. Issues with Diagnoses Example of an issue that would get a diagnosis sent back for corrections: A diagnosis of Adjustment Disorder with Anxiety and Depression is listed on a BPS. • An identifiable stressor is not clearly stated. • The Identifiable stressor was listed but occurred more than 6 months ago. • DSM criteria for adjustment disorder- Once the stressor (or its consequences) has terminated, the symptoms do not persist for more than an additional 6 months.  • A stressor is listed but no info is given about when the stressor occurred. • No info is given about symptoms of anxiety and depression related to the stressor.

11. Substance Abuse Clients Not listing the correct info for a client with substance abuse concerns cause BPS forms to be sent back often. • Clients with substance abuse issues require some extra steps of documentation on the BPS. • If the client has a CAR score in the 30’s or higher in Domain 3, the client needs a substance abuse diagnosis. • If the client has a substance abuse diagnosis and a mental health diagnosis, the middle box needs to be checked on the top of page one of the BPS indicating that the treatment will be integrated, mental health and substance abuse. • If the client only has a substance abuse diagnosis, please check the last box on the top of page one, indicating that the treatment will be substance abuse only. • Discharge criteria - if a client has a substance abuse diagnosis they need to have some clinical discharge criteria related to substance abuse. Ex. “client will remain clean and sober for 90 days prior to discharge.” • On a side note, clients with substance abuse diagnoses will need to have an ASAM assessment and a CM check list form filled out.

12. Not listing enough info. Important! • The summary of assessment, presenting problems, trauma screens, etc., all need to be completed with several details. • Each CAR domain needs enough info to back up the CAR score listed. The info for the CAR score needs to be listed in the actual domain even if you have already listed the info elsewhere in the BPS. • For no issues please list a CAR score of 10. • Scores in the 20-29 range indicate mild to moderate concerns. • Scores in the 30-39 range indicate moderate to severe concerns. • Scores in the 40-49 range indicate severe to incapacitating concerns. • Scores in this rage are highly scrutinized by auditors.

13. How to document symptoms General guidelines for descripting symptoms in a BPS. • The frequency of the behavior (How often does the behavior occur?) • The intensity of the behavior (How severe is the behavior?); • Thedurationof the behavior (How long does the behavior last?); and • The impact the symptoms/behaviors have on daily functioning, to establish theseverity of the customer’s current condition. Examples:   • Client hits, kicks and punches walls 3 times daily (frequency) causing holes in walls and bruises on his brother and school mates (intensity). Anger episodes last from 15-20 mins per episode (duration) and causes him to get suspended from school, being grounded at home and emotional and physical discomfort personally (impact). • Client is Anxious 3 or 4 times per week lasting up to 3 hours at a time as evidenced by motor tension, autonomic hyperactivity, apprehension, and vigilance. When anxious, client talks non-stop and interrupts others 3 or more times daily. Doesn’t respond to encouragement and/or redirection. Client’s behavior has put him at risk of being dropped from college courses and is causing conflict at work.

14. The follow is an example of the amount of information and the appropriate length of an interpretive summary. SAMPLE INTERPRETIVE TREATMENT SUMMARY (INITIAL) He appears to be suffering from an adjustment disorder following abandonment by the mother and placement with the maternal aunt. The biological mother reportedly has substance abuse problems and was extremely neglectful of the children. He will be starting kindergarten. He does not appear to be suffering from any developmental problems or delays. He reportedly functioned within normal limits in preschool this past year. The client’s kindergarten teacher has been contacted and there are plans to collaborate on a monthly basis regarding limit setting and anger management. The client’s Aunt is having difficulty with parenting issues. She describes the client as having angry outbursts 3 or 4 times per week, and they seem to occur at times of limit setting. During the outbursts, he will scream, cry uncontrollably, break objects, and is inconsolable. The severe angry outbursts started after he was abandoned. He is also aggressive with his older siblings. He will hit his siblings for no apparent cause. The aggressive behavior occurs on a daily basis. There is no goal for reunification with the biological mother at this time. The aunt indicates that she is willing to participate in family therapy and is anxious to learn new ways to help the client overcome his behavioral problems. The client appears to have insight and is willing to participate in therapy and attend sessions. Both the aunt and client appear able to meet the treatment objectives. The prognosis is good and measurable improvement in functioning is expected during this initial authorization period. The client will be treated in family and individual therapy. The focus being to help him with the adjustment to living with the aunt, process of dealing with the abandonment issues, and helping the aunt develop effective ways to deal with the client’s behavioral problems. The siblings are not receiving mental health services at this time, but will be participating in family psychotherapy sessions with the client.

15. Common concerns with provided information • Many times BPS forms are sent back because the info listed is not in the correct domain or based on historical info rather than current. BPS forms will also be sent back if the CAR score is too high for the info given. • The information needs to be listed in the correct domain. • Descriptors should be relevant to the domain in which they are documented (i.e., family interactions should be documented in domain 5- the family domain, not in domain 6 which addresses interactions/relationships outside of the family). •  CAR scores need to be based on current info. • Only current information is to be scored, not historical information. Relevant historical information is documented in the Historical Information section of the request. • This is a common concerns in the family domain. To list a CAR score based on past trauma you will need to show how the client is currently impacted by past trauma. • Consider what is “normal” for the client. • Descriptors should be scored considering reasonable expectations for the person’s age, gender, culture and life circumstance to differentiate between expected behavior/symptoms and pathological behavior/symptomology. • EX- you have a client who cries whenever they see a large dog. If the client is 2 this may be an age appropriate reaction. If the client is 15, this is a more significant concern.

16. How to make corrections and resubmit To make corrections to any signed document you will need to right click your electronic signature and select the option to “clear signature”. This will open the document for corrections. Once you are done, resign the document and email the corrections to Leah Holland and the Intakes email. Before resubmitting Forms: • Please double check to make sure all corrections are made. A common mistake is to resubmit forms with only partial corrections. • All corrections requested are necessary for processing. Please don’t skip over anything. When resubmitting corrections please do the following: • List the client’s full name in the email subject • List the document as a CORRECTION in the subject of the email. • Make sure you attached the corrected version of the form to the email rather than the original version.