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1. Neal Adams MD MPH
Diane M. Grieder, M.Ed
2.
Youve got to have a little love in your life and some food in your stomach, before you can hold still for some damn fools lecture about how to behave.
Billie Holiday
4. Although we may do a good job of teaching the best mental health practice available today
we do a poor job of teaching ourselves how to decide when what we learned in the past is no longer good enough and needs to be changed. Neal
Neal
5. Training Objectives Describe the treatment planning process, elements and criteria as a roadmap to recovery and wellness
Identify how emerging new frameworks of person-centered recovery, resiliency and wellness differ from past and current practice to guide the plan of care
Utilize a strengths based person-centered, culturally competent assessment and formulation as basis for treatment / recovery plan roadmap
Assist individuals/families to articulate and prioritize person-centered goals and discharge/transition needs
6. Training Objectives Join in partnership with the client/ family, develop and prioritize objectives, interventions and services that reflect client/family strengths, preferences, choices and stage of change
Facilitate implementation of the plan including timely review and update of the assessment and plan as necessary
Define key elements of documentation (including Medical Necessity) and properly document the elements of the plan and services provided
7. NealNeal
8. President's MH Commission Calls for transformation of the mental health system
Consumers of mental health services must
stand at the center of the system of care.
Consumers needs must drive the care and
services provided.
9. President's MH Commission Goal 2
Mental Health Care is Consumer and Family Driven
Recommendation 2.1
The plan of care will be at the core of the consumer-centered, recovery oriented mental health system
Providers should develop customized plans in full partnership with consumers
10. Setting the Compass
11. Hypothesis Person-centered treatment plans are a key lever of personal and systems transformative change at all levels:
Individual and family
Provider
Administrator
Policy and oversight
NealNeal
12. Person-Centered There is agreement on
Goals
Tasks
Participation and roles
The relationship with the provider is experienced as
Collaborative ? Empathic
Respectful ? Trusting
Understanding ? Hopeful
Encouraging ? Empowering
NealNeal
13. Person-first Language Not a diagnostic label
Person with schizophrenia
not a schizophrenic
Not front-line staff who are in the trenches
Direct care staff providing compassionate care
Focus on strengths, successes, talents
Self-determination as a right
Communicate a consistent message of hope
14. Building a Plan
15. Whats Critical Service plans must
Be developed with the person served and family as a partner
identify the person's own expectations
Be consistent with culture and personal (and family as appropriate) preferences
Recognize that participation may vary
personal style
age and development
cultural traditions and expectations
severity of needs
16. What Do People Want? Commonly expressed goals of persons served
Manage their own lives ? Quality of life
Social opportunity ? Education
Activity / Accomplishment ? Work
Transportation ? Housing
Spiritual fulfillment ? Health / Well-being
Satisfying relationships
... to be part of the life of the community Diane if the consumers had an opportunity to be involved in goal setting , they typically identify these goal areas, yet we still write on the plans be medication compliant, commit to abstinence and life long recovery, Diane if the consumers had an opportunity to be involved in goal setting , they typically identify these goal areas, yet we still write on the plans be medication compliant, commit to abstinence and life long recovery,
17. Oranga Ngakau Oranga
satisfaction, comfort, contentment
survivor
Ngakau
heart, seat of affections or feelings, mind, inclination, desire, spirit
source of emotions
18. Oranga Ngakau Reclaiming oneself by seeking what is needed to be content with who we are so we can nurture our self determination by taking care of ourselves and fulfilling our dreams and desires
19. Example Goal
Stuart will receive the assistance he needs to make decisions that best meet his needs and to keep his entitlements current
Objectives
Stuart will be
compliant with meds
compliant with scheduled appointments
compliant with having his blood drawn
Diane
Goal I sometimes find it difficult to manage my needs and often get depressed due to my back problems
Objectives keep all medical appts.
will attend ClubhouseDiane
Goal I sometimes find it difficult to manage my needs and often get depressed due to my back problems
Objectives keep all medical appts.
will attend Clubhouse
20. Example Goal
Decrease depression
Objectives
assess medication needs
improve finances
develop appropriate vocational goals Diane goal not framed in positive language. Objectives written like goal statements, not specific enough, measurable,
Debbie will display appropriate behavior..
Goal - Ms. .will maintain improved mood and functioning.
Objectives: will report he is maintain an overall positive mood, will maintain current level of functioning "will report she is doing better at not internalizing stress
Diane goal not framed in positive language. Objectives written like goal statements, not specific enough, measurable,
Debbie will display appropriate behavior..
Goal - Ms. .will maintain improved mood and functioning.
Objectives: will report he is maintain an overall positive mood, will maintain current level of functioning "will report she is doing better at not internalizing stress
21. The Right Balance Diane Patricia - Degan at BU- intentional careDiane Patricia - Degan at BU- intentional care
22. Intentional Care Clients should have the dignity of risk and right of failure
Providers are advocates of client choice
Clients are not abandoned to suffer the natural consequences of their choices
Provider or client not a failure if choice results in failure
Use reinforcers to support client choice
Assure true choice over a wide range of options dianediane
23. Serving Two Masters Person-centered
Recovery
Community integration
Core gifts
Partnering
Supports self-direction Regulation
Medical necessity
Diagnosis
Documentation
Compliance
Billing codes
24. Letter of the Law Compliance
Ensure taxpayer funds well spent
Prevent fraud and abuse
services claimed are provided
medical necessity is met
scope of practice
services reflected in plan document
medical necessity met for unanticipated services
25. Medical Necessity
Doing the right thing, at the right time, for the right reason
Standard of service and quality
Five elements
Indicated
Appropriate
consider issues of culture
Efficacious
Effective
Efficient
26. Plan Development Acquired skill / Art form
Not often taught in professional training
Often viewed as administrative burden and paper exercise
Requires flexibility
Opportunity for creative thinking
Integrates information about person served
Derived from formulation and prioritization
Information transformed to understanding
Strategy for managing complexity
27. Service Plan Functions Specifies intended outcomes / transitions / discharge criteria
Clearly elaborates expected results of services
includes perspective of person served and family in the context of the persons culture
Promotes consideration and inclusion of alternatives and natural supports / community resources
Establishes role of person served and family in their own recovery / rehabilitation
Assures that services are person-centered
Enhances collaboration between person served and providers
28. Service Plan Functions continued Identifies responsibilities of team members--including person served and family
Increases coordination and collaboration
Decreases fragmentation and duplication
Coordinates multidisciplinary interventions
Prompts analysis of available time and resources
Provides assurance / documentation of medical necessity
Anticipates frequency, intensity, duration of services
Promotes culturally competent services
29. Service Plan Functions continued Supports utilization management
Services authorization, communication with payors and payment for services
Allocation of limited resource
30. Large group discussion
What I heard
What I liked about what I heard
What questions or concerns do I have now?
31. A Plan is a Road Map Provides hope by breaking a seemingly overwhelming journey into manageable steps for both the provider and the person served
32.
A plan is only as good as the assessment.
33. Assessment Initiates helping relationships
Ongoing process
Comprehensive domain based data gathering
Identifies strengths
Abilities and accomplishments
Interests and aspirations
Recovery resources and assets
Unique individual attributes
Considers stage / phase of change process
Must include a cultural formulation
34. SNAP
35. The Importance of Culture Culture and social contexts shape individual's mental health
Symptoms, presentation and meaning
Coping styles
Family influences
Help seeking
Stigma
Trust
36. Cultural Elements Person / provider relationship shaped by differences in culture and social status
Impact clinical encounter
Communication
Rapport
Disclosure
Privacy
Trust
Power
Dignity
Respect
37. Cultural Factors in Assessment Begin with cultural and demographic factors
Clarify identity
how do you see yourself?
race, ethnicity, sexual orientation, religion, color, disability reference group
Specify language
fluency
literacy
preference
38. Ohio Outcomes/Scales Scores are listed on the assessment
additional data for assessment purposes
meaning of them should be incorporated into the interpretive summary
used for developing the goals on the ISP
used over time for ISP updates
Different scores can be a point of dialog between parent/provider/consumer
Opportunity for partnering
39. Ohio Outcomes/Scales Adults: Consumer Form A & B, Provider Form A
Four scores in the SOQIC documents:
Quality of life
Symptom distress
Empowerment
Community functioning
Youth: Ohio Scales Y- Form (12-18), P-Form (Parent of 5-18), W-Form (Provider for youth 5-18)
Two scores in the SOQIC documents:
Problem severity
Functioning
40. Importance of Understanding Data collected in assessment is by itself not sufficient for service planning
Formulation / understanding is essential
Requires clinical skill and experience
Moves from what to why
Sets the stage for prioritizing needs and goals
The role of culture and ethnicity is critical to true appreciation of the person served
Recorded in a chart narrative
Shared with person served
41. Understanding Identifies individual's and familys strengths
Identifies stages of change/recovery
It helps determine priorities
Accounts for choice and preference
Enables everyone to see the interrelationships in the persons life
It serves as the context for the plan
It clarifies the order in which objectives need to be addressed sequential or concurrent
42. Outline for Cultural Formulation DSM-IV
Inquire about cultural identity
Explore possible cultural explanations of illness
Consider cultural factors related to psychosocial environment and levels of functioning
Examine cultural elements in the client provider relationship
Include overall cultural assessment in diagnosis and service plan
43. Formulation Makes assessment data meaningful
Involves clinical skill
Critical value added component of entire service process
Narrative summary
A few paragraphs
More than just a re-telling of history / facts
Provide synthesis, analysis, insight, hypothesis
Can include diagnosis and rational
Becomes the basis of creating the plan
Understanding the why leads to informed tactics and success
44. The 8 Ps P ertinent history (brief)
P redisposing factors
P recipitating factors
P erpetuating factors
P resent condition / presenting problem
P revious treatment and response
P rioritization by person serve
P references of person served
45. Prioritization by Person Served What comes first?
Personal / family values need to be considered
Cultural nuances are significant
Must be the driving force
Consistent with concerns / perspective of person served (and family as appropriate)
Builds upon person served's own expertise
46. Provider Perspectives in Prioritization Basic health and safety
Maslow
food, clothing, shelter
affection, self esteem
freedom, beauty, goodness, justice
self-actualization
self-transcendence
Harm reduction
Legal obligations and mandates
47. Stages of Recovery and Treatment
48. Vignette--Carmen 18 year old Latina
High school senior
preparing for graduation
First generation
parents monolingual Spanish speaking
client bilingual
observant Catholic family
Lives in predominantly Anglo-American community
49. Vignette continued Excellent student
Active in school and social activities
Recently unable to attend school because of distress
Graduation from high school and college attendance is core value for Carmen and family
Recent physical problems
Nausea, vomiting, dizziness, headaches
Parents believe she is suffering from susto
Treatment from curandero
50. Vignette continued Recent crisis
Acute physical distress
Admitted to hearing a baby cry while at school
Reported feeling sad and blue
Referred to mental health
Embarrassed and resistant
First family member to seek MH services
51. Vignette continued Assessment with Latina provider in Spanish
Revealed she had a miscarriage a year ago
Feeling increasingly guilty and troubled
Wants to die and join her baby
Relationship with parents has become distant and conflictual
father refusing to speak with her
52. Vignette Formulation Identity
First generation Latina
Bilingual
Explanation of Illness
What appeared to be a physical problem is a mental health problem
somatization is idiom of distress
shame, guilt and embarrassment are key themes
Provider relationship
Spanish preferred
More open with Latina clinician
53. Vignette Formulationcontinued Psychosocial environment
Lives with family, first generation
Some degree of acculturation and distance from parents
difficult and painful
Diagnosis
Consider possibility of culture bound syndrome
Susto
Possible depression with psychotic features
Understanding her beliefs may be key to treatment
54. Vignette Formulationcontinued Hypothesis
Intergenerational issues of acculturation are a major factor
Age appropriate issues of individuation and separation
She is between contemplative and active stagesome ambivalence about help-seeking
School completion and education opportunity and advancement are shared values /strengths to build upon
Need to help her reconcile feelings of guilt and remorse
Religious and spiritual factors may be significant
55. Small Group Exercise Utilizing the sample assessments provided, write an interpretive (clinical) summary
Utilize the team expertise to develop this summary
Write your summary on a piece of paper and save it for the afternoons group work
You have 45 minutes to accomplish the task
56. Goals Long term, global, and broadly stated
The broader the scope the less frequently it needs to change
Perception of time may be culture bound
may influence expectations and participation
may need to explain type and / or level of service
Life changes as a result of services
Focus of alliance / collaboration
Readily identified by each person
Linked to discharge / transition criteria and needs
Should describe an end point of helping relationship
57. Goal Directed
58. Goals continued Person-centered
Ideally expressed in person serveds / familys words
Easily understandable in preferred language
Appropriate to the persons culture
reflect values, life-styles, etc.
Consistent with desire for self-determination and self-sufficiency
may be influenced by culture and tradition
Three types
Life goals
Treatment goals
Quality of life / enhancement goals
59. Goals continued Essential features
Attainable
one observable outcome per goal
Realistic
Written in positive terms
built upon abilities / strengths, preferences and needs
embody hope
alternative to current circumstances
60. Carmens Plan Goal
I want to graduate from high school
61. Barriers What is keeping the person from their goals?
Need for skills development
Intrusive or burdensome symptoms
Lack of resources
Need for assistance / supports
Problems in behavior
Challenges in activities of daily living
Threats to basic health and safety
Challenges / needs as a result of a mental / alcohol and drug disorder
62. Objectives Work to remove barriers
Culture of persons served shapes setting objectives
Address culture bound barriers
Expected near-term changes to meet long-term goals
Divide larger goals into manageable tasks
Provide time frames for assessing progress
Maximum of two or three per goal recommended
63. Objectives
Build on strengths and resources
Essential features
Behavioral
Achievable
Measurable
Time framed
Understandable for the person served
Services are not an objective
64. Objectives Appropriate to the setting / level of care
Responsive to the persons individual
disability, challenges and recovery
Appropriate for the persons age, development and culture
The individual / family will
Changes in behavior / function / status
Described in action words
65. Carmens Plan Goal
I want to graduate from high school
Objective
Carmen will return to class attendance for 5 consecutive full days within a month as reported by Carmen / or support worker
66. Interventions Actions by person served, family, peers, staff and and the entire system of care
may include family, support network, etc.
Specific to an objective
Cultural efficacy must be considered
Availability and accessibility of services may be impacted by cultural factors
67. Six Critical Elements Interventions must specify
Provider and clinical discipline
Staff members name
Modality
Frequency /intensity / duration
Purpose / intent / impact
Clarifies who does what
Include a task for the client and/or family, or other component of natural support system to accomplish
68. Stage Specific Responses Precontemplation
Engagement
focus of the practitioner is to develop a therapeutic alliance
support persons immediate needs and foster hope
Contemplation
Persuasion and Motivational Interviewing
practitioner assists the person to see the negative consequences of his/her behavior
remain allied with the person
nonjudgmental and supportive
assist in goal identification
69. Stage Specific Responses Action
Active treatment
assist person in working on goals set in persuasion stage
may provide individual cognitive-behavioral therapy or group therapy
slips from treatment goals are viewed as learning opportunities rather than failures
all success is celebrated
Maintenance
Relapse prevention
practitioner continues to be supportive on an ongoing basis
assists person to see and manage risks of relapse
70. Carmens Plan Sample interventions
Psychiatrist to provide weekly to monthly pharmacotherapy management visits for 3 months to relieve acute symptoms of anxiety and depression
Social worker to provide one hour of cognitive-behavioral psychotherapy twice a week for 4 weeks to help Carmen resolve feelings of guilt and loss
Support worker to meet with Carmen up to 3 hours / week for 4 weeks as required to coordinate / facilitate return to school with school counselors and mental health team
Carmen to attend teen support group at community center weekly for 3 months to address with peers issues of identity and acculturation
71. Review / Evaluation Reassess plan at clinically appropriate intervals
Determine effectiveness
Re-evaluate appropriateness
Input of person served / family essential
Plan revisions
Concerns / needs
Formulation
Goals / discharge
Objectives
Interventions / modalities
Time frames and target dates
72. Writing an ISP Exercise In your small group teams, utilizing the written interpretive summary, write at least one goal, 1 objective and several interventions for your sample case
Write your plans on the overhead provided
Each team/group needs a spokesperson
Large group review and discussion
73. Lessons Learned Identify assessment and/or ISP components your agency needs to develop more or improve upon
What will you do to encourage the leaders of your organization to make the changes you have identified?
How will the change benefit your consumers, their families, and your organization?
What resources does your organization need to improve its assessment and treatment planning processes?
74. Workshop Summary Topics that were covered during this day:
The business case for treatment planning
Introduction to a comprehensive assessment
Interpretive summary writing practice
Incorporating assessment findings into treatment plans
Components of a person-centered treatment plan
Putting it all together exercise
Lessons learned and applications
75. Common Mistakes Assessment
Do not use all available information resources
Not culturally appropriate / sensitive
Not sufficiently comprehensive
Lack adequate integration / understanding of the person
76. Common Mistakes Goals
Not global
Not directed towards recovery
Not responsive to need
Not strengths based
Too many
77. Common Mistakes Objectives
Dont support the goal
Not measurable or behavioral
Interventions become objectives
Not time framed
Too many simultaneous objectives
78. Common Mistakes Interventions
Purpose not included
Frequency, intensity, and duration not documented
Too few
Dont reflect multidisciplinary activity
79. A Plan is a Road Map Provides hope by breaking a seemingly overwhelming journey into manageable steps for both the provider and the person served
80. Creating the solution The treatment / recovery management plan can be the bridge between the system as it exists now and where we need to go in the future
NealNeal
81. When you come to a fork in the
road, take it.
Yogi Berra
82.
If you dont know where you are going, you will probably end up somewhere else.
Lawrence J. Peter