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TREATMENT PLAN

TREATMENT PLAN . DOCUMENTATION REQUIREMENTS Eda Oteri, RN, MSN, CQA August 24, 2011. ADHD - Attention Deficit Hyperactivity Disorder

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TREATMENT PLAN

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  1. TREATMENT PLAN DOCUMENTATION REQUIREMENTS Eda Oteri, RN, MSN, CQA August 24, 2011

  2. ADHD - Attention Deficit Hyperactivity Disorder AHCA - Agency for Health Care Administration BHOS - Behavioral Health Overlay Services CBC – Community Based Care CBH - Community Behavioral Health CW - Child Welfare DCF - Department of Children & Families DJJ - Department of Juvenile Justice e.g. - for example (exempli gratia) Handbook - Community Behavioral Health Coverage and Limitations Handbook i.e. - that is (id est) Acronyms & Abbreviations Magellan Medicaid Administration | 2

  3. JJ - Juvenile Justice LPHA - Licensed Practitioner of the Healing Arts MMA - Magellan Medicaid Administration N/A - Not Applicable NA - Narcotics Anonymous NOS - Not Otherwise Specified ODD - Oppositional Defiant Disorder PTSD - Post Traumatic Stress Disorder R/O - Rule Out SIPP - Statewide Inpatient Psychiatric Program TBOS - Therapeutic Behavioral On- Site Services TGCS – Therapeutic Group Care Services Acronyms & Abbreviations Magellan Medicaid Administration | 3

  4. This presentation is intended to be an overview of documentation requirements for the development of a treatment plan. Its purpose is to act as a guide for many of the pertinent documentation requirements and therefore may not cover ALL requirements. It is the provider’s responsibility to review and continually utilize applicable state and/or federal rules, regulations, and contractual requirements. PLEASE NOTE Magellan Medicaid Administration | 4

  5. Training Objectives List a minimum of three (3) requirements of treatment plan development applicable to the provider’s specific program Identify and document a measurable treatment plan objective Document prescribed services as required Magellan Medicaid Administration | 5

  6. RESOURCES FOR DOCUMENTATION CBH 05 Providers CBH Handbook (http://mymedicaid-florida.com) Magellan Medicaid Administration Interpretive Guidelines (http://florida.fhsc.com) Magellan Medicaid Administration | 6

  7. RESOURCES FOR DOCUMENTATION CBH Handbook (October 2004 Revised Handbook) Documentation Requirements Chapter 2, Section 1 (pg.2-1-2) Treatment Planning Chapter 2, Section 1 (pgs. 2-1-15,16,17) Magellan Medicaid Administration | 7

  8. RESOURCES FOR DOCUMENTATION BHOS JJ Chapter 2, Section 4 (pgs. 2-4-1 through 2-4-20) BHOS CW Chapter 2, Section 7 (pgs. 2-7-1 through 2-7-21) TGCS Chapter 2, Section 6 (pgs. 2-6-1 through 2-6-24) Magellan Medicaid Administration | 8

  9. Resources for Documentation SIPP Providers • AHCA Contract No. FA929, Attachment II, Pgs. 1-52 • Chapter 65E-9F.A.C. (Residential Treatment Center) • Chapter 395, F.S. (Hospital) • Chapter 397, F.S. (Substance Abuse Services) Magellan Medicaid Administration | 9

  10. Resources for Documentation GENERAL GUIDELINE If there is a conflict in requirements for documentation then follow the most restrictive requirement Magellan Medicaid Administration | 10

  11. Treatment Plan “The individualizedtreatment plan is a structured, goal-oriented schedule of services developed jointly by the recipient and the treatment team. The plan must contain written treatment-related goals and measurable objectives.” Medicaid’s Community Behavioral Health Coverage and Limitations Handbook, Treatment Plan Development, page 2-1-15 Magellan Medicaid Administration | 11

  12. Treatment Plan SIPP AHCA Contract No. FA929, Attachment II, page 4 of 52 * states: The Individualized Treatment Plan is a written plan of care developed for each enrollee. The plan of care must: • Be based on a diagnostic evaluation • Be developed with an interdisciplinary team of physicians and other personnel • State treatment objectives • Prescribe an integrated program designed to meet objectives • Include post discharge plans and coordination of services * Refer to AHCA Contract for details to each bullet Magellan Medicaid Administration | 12

  13. Treatment Plan Merriam-Webster defines individualized: “to adapt to the needs or special circumstances of an individual.” Information learned on admission from various resources, including assessments, provides treatment team with data needed to develop an individualized treatment plan. The sum of all this information provides a picture of what makes one client’s needs different from another client’s needs and how to best develop the goals and objectives based on these unique clinical needs and differences. Magellan Medicaid Administration | 13

  14. Client’s psychiatric and substance abuse history Family history Cultural and spiritual beliefs Experiences with previous treatment facilities and modalities Personal strengths and limitations Developmental age of client Cognitive abilities Willingness to acknowledge problems Willingness to change Medical issues Variables that Foster Individuality Magellan Medicaid Administration | 14

  15. Difficulties with Individualizing Treatment Plans Treatment plan documentation related to intensity of services, goals, objectives, and discharge criteria basically the same for several or all clients and not individualized. Magellan Medicaid Administration | 15

  16. Training Definitions Diagnostic Impression Diagnosis or diagnoses after completion of assessment/assessments Licensed Practitioner of Healing Arts (LPHA) Psychiatric/registered nurse, mental health counselor, clinical social worker, psychologist, etc. Magellan Medicaid Administration | 16

  17. Training Definitions Treating Practitioner A licensed practitioner of the healing arts, psychiatrist, or other physician, who authorizes services on behalf of the Medicaid group provider Must be independently enrolled in Medicaid: physicians as a 25, LPHA as an 07 and must also be affiliated with the group provider Magellan Medicaid Administration | 17

  18. Training Definitions Target Date The anticipated date of completing a measurable objective Duration of Prescribed Services The anticipated length of time needed to provide prescribed service, such as: - individual therapy, weekly for 60 min., for 4 months - biopsychosocial evaluation, once, annually Magellan Medicaid Administration | 18

  19. Prior to Development of Treatment Plan Face-to-face assessment by a licensed practitioner of the healing artsprior to development of treatment plan CBH 05 Providers Brief Behavioral Health Status Examination, Psychiatric Evaluation, or other assessment performed by a licensed practitioner of the healing arts (LPHA) An assessment completed by an LPHA within the last six (6) months may be used to satisfy requirement SIPP Providers Board Certified or Board Eligible Psychiatrist Magellan Medicaid Administration | 19

  20. Development of Treatment Plan Time Requirement CBH 05 Providers Medicaid will reimburse for services 45 days prior to the authorization date. The treatment plan becomes effective on the date it is authorized, i.e., signed and dated by the treating practitioner Magellan Medicaid Administration | 20

  21. Development of Treatment Plan Time Requirement BHOS DJJ Providers • Within thirty (30) days from admission BHOS CW Providers • Within thirty (30) days from initiation of services TGCS Providers • Within fourteen (14) days from admission SIPP Providers • Within fourteen (14) calendar days of admission Magellan Medicaid Administration | 21

  22. Treatment Plan Required Components • Client’s ICD-9-CM diagnosis code(s) consistent with assessments • Goals appropriate to client’s diagnosis, age, culture, strengths, abilities, preferences, and needs expressed by client • Measurable objectives and target dates • A list of services to be provided Magellan Medicaid Administration | 22

  23. Treatment Plan Required Components • Amount, frequency, and duration of each service • Signature of client If client’s age/clinical condition precludes participation in signing plan then an explanation must be provided • Signature of client’s parent/guardian if under 18 years old Magellan Medicaid Administration | 23

  24. Treatment Plan Required Components Exceptions to Required Signature of Parent/Guardian • Clients less than 18 yrs. of age seeking substance abuse services from a licensed provider • Clients in custody of DJJ that have been court ordered into treatment; or emergency treatment that if delayed would endanger mental or physical well being of client . However, signature of parent/guardian must be obtained as soon as possible after emergency treatment is administered Magellan Medicaid Administration | 24

  25. Treatment Plan Required Components Exceptions to Required Signature of Parent/Guardian • Clients in custody of DCF or CBC must sign treatment plan if it is not possible to obtain parent’s signature. The caseworker and foster parent should be encouraged to participate in treatment planning. In cases where DCF is working towards reunification, the parent should be involved and sign the treatment plan. Magellan Medicaid Administration | 25

  26. Treatment Plan Required Components Exceptions to Required Signature of Parent/Guardian • Clients age 13 or older experiencing an emotional crisis to the degree that client perceives the need for professional assistance. Client can request and give consent for mental health diagnostic & evaluation services & outpatient crisis intervention services by a LPHA or in a state licensed mental health facility. Services will not exceed two (2) visits during any one (1) week period in response to crisis before parental consent is required for further services. Magellan Medicaid Administration | 26

  27. Treatment Plan Required Components • Dated signatures of treatment team members who participated in development of the plan • A signed and dated statement by treating practitioner that services are medically necessary and appropriate to client’s diagnosis and needs • Transition or discontinuation of services (CBH 05 providers) Magellan Medicaid Administration | 27

  28. Required Component of Treatment Plan ICD-9-CM Diagnosis Diagnostic impression after completion of assessment(s) WHY IS AN ACCURATE DIAGNOSIS ON TREATMENT PLAN IMPORTANT? Magellan Medicaid Administration | 28

  29. Required Component of Treatment Plan Importance of Diagnosis • Aids in identifying problems to be addressed • Problems related to diagnosis will then drive individualized goals and objectives Magellan Medicaid Administration | 29

  30. Treatment PlanDifficulties with Diagnostic Impressions Documented diagnostic impression on treatment plan is not comprehensive and lacks written explanation for absence of a diagnosis Example Psychiatric Evaluation has an Axis I diagnostic impression that includes Depression and Cannabis Abuse. Depression was the only diagnosis noted on treatment plan and there was no written explanation for the omission of Cannabis Abuse. Magellan Medicaid Administration | 30

  31. Treatment PlanDifficulties with Diagnostic Impressions Assessments have different diagnostic impressions and documentation does not reflect resolution to variances Example Psychiatric Evaluation has an Axis I of ADHD, Mood Disorder NOS, and Axis II Mental Retardation. LPHA evaluation has Axis I ADHD and rule out Oppositional Defiant Disorder. The LPHA diagnostic impression is only documented on plan. There was no written explanation for why the psychiatrist’s diagnoses were not on plan and/or how the variance in diagnoses was resolved. Magellan Medicaid Administration | 31

  32. Treatment PlanDifficulties with Diagnostic Impressions Diagnoses have rule out impressions that were not resolved and/or never changed on Treatment Plan Example Psychiatric Evaluation’s Axis I has Major Depression as well as R/O Oppositional Defiant Disorder. These both were documented on treatment plan. • Documentation in MD progress note changes R/O to a definitive diagnosis but doesn’t get documented on plan • Documentation does not reflect that the R/O ever gets resolved Magellan Medicaid Administration | 32

  33. Treatment Plan Required Components Objectives • Objectives that are measurable with target dates • Written in language that is easy for the client and family to understand Magellan Medicaid Administration | 33

  34. Treatment Plan Difficulties with Objectives • Varied definitions/meanings used by providers for problems and objectives, e.g., diagnoses documented as problem vs. the documentation of problems as a result of diagnosis; desired outcomes documented vs. objectives • Documenting objectives that were not measurable and/or focusing measurement on time frames vs. the objectives • Language was too clinical for client/family to easily understand Magellan Medicaid Administration | 34

  35. Treatment PlanDifficulties with Objectives Examples of: Desired Outcomes vs. Objectives Measurement on Time Frame vs. Measurable Objectives • Client will display no aggressive behavior for 45 days • Client will not run away for 30 consecutive days • Client will attend all medication sessions with psychiatrist and take medication as prescribed Magellan Medicaid Administration | 35

  36. Treatment Plan Difficulties with Objectives Language too clinical for client/family to fully understand Example Six (6) year old male with ADHD has following goal and objective: Goal: Client will acknowledge deficits in concentration and be able to verbalize internal struggles more appropriately Objective: Client will identify three (3) negative influential external factors that exacerbate disruptive behaviors Magellan Medicaid Administration | 36

  37. Treatment PlanTraining Definitions Problem A source of difficulty/trouble which results from issues related to diagnostic impression Goal The purpose toward which efforts are directed; usually not measurable; broad in scope; often based on an idea Objective Steps/actions taken in the hopes of reaching goal; measurable; narrow in scope; based on fact Magellan Medicaid Administration | 37

  38. Treatment Plan Required Components Examples of Measurable Objectives (continued on next slide #39) Diagnosis: 312.81 Conduct Disorder Problem: Initiates physical fights with peers 3 x week Goal: Increase awareness of why client gets into fights and eliminate physical aggression towards others Magellan Medicaid Administration | 38

  39. Treatment Plan Required ComponentsExample of Measurable Objectives(continued from slide #38) Objective #1: Client will identify 3 triggers or situations that lead to physical aggression/fights with others Objective #2: Learn and implement 4 options or plans that will be used in place of physical fights Magellan Medicaid Administration | 39

  40. Treatment Plan Required ComponentsExample of Measurable Objectives(continued on slide #41) Diagnosis: Cocaine Dependence Problem: Several year history of cocaine use progressing from weekend use to daily use of crack. Efforts to stop on own have failed. Client lacks knowledge of addiction or skills for abstinence. Goal: Develop knowledge, insight, and skills to reduce likelihood of continued use of cocaine upon discharge from treatment. Provide evidence of abstinence. Magellan Medicaid Administration | 40

  41. Treatment Plan Required ComponentsExample of Measurable Objectives(continued from slide #40) • Objective #1: Client will identify and list 5 situational triggers, 5 visual triggers, 5 peer triggers, and 5 emotional triggers for drug use • Objective #2: Client will list 5 perceived benefits and 5 negative consequences of own drug use • Objective #3: Client will attend one NA meeting daily and read Just for Today meditation daily Magellan Medicaid Administration | 41

  42. Treatment Plan Required ComponentsExample of Measurable Objectives(continued on slide #43) Diagnosis: 295.30 Paranoid Schizophrenia Problem: Forgets to take medication as prescribed at least 4 x a week and misses appointments with psychiatrist at a minimum of once per month Goal: Consistency in taking medications at least 6 out 7 days a week; attend every psychiatrist session Magellan Medicaid Administration | 42

  43. Treatment Plan Required ComponentsExample of Measurable Objectives(continued from slide #42) • Client will learn and be able to list 4 potential positive side effects from taking medication as prescribed • Client will identify 2 possible side effects from taking medication and will identify 2 options should medication cause unpleasant effects • Client will list 3 situations/reasons that result in missing scheduled appointments with psychiatrist • Client will learn and implement 3 options for ensuring that client attends each appointment as scheduled Magellan Medicaid Administration | 43

  44. Treatment Plan Required Components Prescribed services on treatment plan that include Amount, Frequency, and Duration A list of services to be provided (Treatment Plan Development, Treatment Plan Review, and Comprehensive Behavioral Health Assessment need not be listed). Magellan Medicaid Administration | 44

  45. Treatment Plan Required Components Prescribed services on treatment plan that include Amount, Frequency, and Duration • BHOS, TGCS, and SIPP need to include Therapeutic Home Visits on treatment plan • TGCS must identify clinician responsible for individual and group therapy Magellan Medicaid Administration | 45

  46. Treatment Plan Required Components Prescribed services on treatment plan that include Amount, Frequency, and Duration • SIPP must also include name of staff responsible for providing the services. A specific clinician’s name should be documented for child and family therapy. • SIPP must include Time-outs on treatment plan. Magellan Medicaid Administration | 46

  47. Treatment Plan Required Components Prescribed services on treatment plan that include Amount, Frequency, and Duration • It is not permissible to use terms “as needed,” “prn,” or to use ranges such as “x to y times per week.” • SIPP need to include Time-outs and per AHCA contract have some services that are required to be prescribed Magellan Medicaid Administration | 47

  48. Treatment PlanDifficulties with Prescribed Services • Documentation of amount and/or frequency and/or the duration with one or more services is missing • Fail to document a service that was delivered such as: Biopsychosocial Evaluations, Psychiatric Evaluations, Therapeutic Home Visits, etc. • Tendency to not document BHOS Services and/or Therapeutic Behavioral On Site Services with specifics Magellan Medicaid Administration | 48

  49. Treatment Plan Required ComponentsAmount, Frequency, Duration Examples of Documenting Services with Amount, Frequency, Duration • Psychiatric Evaluation once per year Biopsychosocial Evaluation once per year • Individual Therapy, 60 minutes once per week, for 3 months • Time-out, 2 x week for 5 minutes at a time not exceeding 30 minutes, for three (3) months Magellan Medicaid Administration | 49

  50. Treatment Plan Required ComponentsAmount, Frequency, and Duration Example of Documenting Service with Amount, Frequency, Duration • TBOS Therapy, 60 minutes once per week for 4 months • TBOS Behavior Management, 45 minutes once a week for 2 months • TBOS Therapeutic Supportive Services, 3 units per week for 4 months Magellan Medicaid Administration | 50

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