treatment planning 101: a clinicians guide to objective ... sessions/aocc 2015... · a counselors...

10/15/2015

Gilea & O'Neill (2015) 1

A Counselors Guide to Objective, Measurable, Obtainable and Reimbursable Treatment Plans

Rachel M. O’Neill, Ph.D., LPCC-S Brandy L. Gilea, Ph.D., LPCC-S, NCC, CDCA

O’Neill & Gilea Mental Health Consultants [email protected]

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About the Presenters

Brandy Kelly Gilea earned her Ph.D. in Counselor Education and Supervision from

Kent State University and her Master’s Degree in Mental Health Counseling from Youngstown State University. She is an Ohio-Licensed Professional Clinical Counselor with Supervisory Designation, Nationally Certified Counselor, and Chemical Dependency Counselor Assistant. Dr. Kelly Gilea has several refereed journal articles and book chapters, as well as a presentation record of nearly 50 international, national, state, and local conferences and workshops. She has over 10 years of experience in Behavioral Health Treatment.

Rachel Hoffman O’Neill earned her Ph.D. in Counselor Education and Supervision from Kent State University and her Master’s Degree in Mental Health Counseling from Youngstown State University. She is an Ohio-Licensed Professional Clinical Counselor with Supervisory Designation. Dr. O’ Neill has authored over 20 scholarly journal articles and book chapters. She has presented over 70 times at national, state, and local conferences and workshops. She has over 10 years of experience in Addiction and Mental Health treatment.

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Objectives

• Participants will learn to write objective and measurable goals, interventions and techniques that are evidence-based.

• Participants will learn to write treatment plans that consider clients’ strengths and interests, diagnoses and stages of change.

• Participants will to write treatment plans that consider payer source and compliance standards.

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Good Treatment Planning

• Client-centered

• Objective and measurable (empirically-supported)

• Obtainable (goals and objectives)

• Reimbursable

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Components of a Treatment Plan • Problem selection (e.g., diagnosis, focus of treatment)

• Problem definition (e.g., diagnostic criteria/symptoms, level of adaptive functioning)

• Goal development (e.g., long-term outcomes of treatment)

• Objectives (e.g., short-term, measureable, behavioral goals likely to be completed during treatment)

• Intervention (e.g., empirically-supported techniques used by counselor or social worker)

Adapted from:

Kress, V. E., & Paylo, M. J. (2015). The Foundations of Treatment Planning: A Primer. In. V. E. Kress and M. J. Paylo (Eds.), Treating those with mental health disorders: A comprehensive approach to case conceptualization and treatment. (1st ed., pp. 1-24). Upper Sadler River, NJ: Pearson.

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Additional Considerations

• Diagnosis and symptoms

• Symptom severity

• Symptom salience (e.g., presence of suicidal ideation)

• Client’s distress

• Level of adaptive functioning/severity of impairment (World Health Organization Disability Assessment Schedule; WHODAS)

• Disability related to the disorder

• Gender and Culture

• Cognitive, emotional, behavioral, and physiological processes that co-occur with the symptom set

• Stage of change

• Past response to treatment

• Baseline level of functioning (caution setting goals too high)

• Any other important considerations

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COMPLIANCE CONSIDERATIONS

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Compliance Considerations

• International and National Accreditation (e.g., Commission on Accreditation of Rehabilitation Facilities (CARF), The Joint Commission (JCO), Council on Accreditation (COA)

• State Compliance Standards (e.g., Ohio Department of Mental Health and Addictions Services (MHAS), Administrative Code/Law)

• County Behavioral Health Boards

• Agency Policies and Procedures

• Managed Care Systems, Private Insurance, Payer Source

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International and National Accreditation • Non-profit organization

• Promote quality services and positive treatment outcomes

• Each accrediting body has standards that must be met to earn accreditation

• Accredited programs and agencies are evaluated at set periods (e.g., every three years) to determine ongoing accreditation

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Ohio Department of Mental Health and Addictions Services (MHAS) • Offer state-level licensing and certification


• Approve/offer funding for services

• NOTE: often govern the content of treatment notes/plans and frequency of updates (e.g., treatment plans must be updated annually or every 90 days)

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County Behavioral Health Boards • Offer county-level licensing and certification (e.g., grant-

funded programs


• Approve/offer funding for services

• Usually comply with state standards

• NOTE: often govern the content of treatment notes/plans and frequency of updates (e.g., treatment plans must be updated annually or every 90 days)

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Agency Policies and Procedures • Unique to each institution

• Most agencies have policies specific to documentation standards

• Policies and procedures should comply with international and national accreditation, state law and ethical codes, state and county level regulatory bodies

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Managed Care Systems, Private Insurance, Payer Source • Ensure quality of care

• Ensure consistent/empirically-supported practices are used

• Control cost

• GOAL – finance heath care that is medically necessary and cost-effective through the use of empirically-supported techniques and interventions

• Hold providers accountable: may need to justify services

• Determine number of sessions and approved services (e.g., counseling, psychiatric case, community psychiatric support treatment)

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THE GOLDEN THREAD

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The Golden Thread

• Treatment planning starts with the diagnosis/symptoms

• Goal, objectives and interventions are directly tied to the diagnosis (e.g., can not diagnose a client with BiPolar I disorder and identify goals connected to symptoms of Schizophrenia)

• Goals, interventions and interventions from treatment plan should be reflected in progress notes (should not diagnose a client with BiPolar I, develop goals, objectives and interventions connected to BiPolar I and then use an intervention associated with Substance Use in session and document on the progress note)

• NOTE: Examples of THE GOLDEN THREAD noted throughout presentation through the use of gold, underlined font

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USEFUL TOOLS

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Helpful Questions

• What are the main points here? • What experiences and actions are most important? • What symptoms are being reported? • What themes are coming through? • What is her/his point of view/worldview? • What is most important to her/him? • What does her/she want me to understand? • What decisions are implied in what she/he is saying? • What is she/her proposing to do? • What background, circumstances surround this client’s life and affects

the way the client understands and deals with their problems? • What age related psychosocial/developmental tasks is the

student/client facing? • How does the client construct meaning (i.e. determining what is

important and right)? • How does the clients personality style and temperament affect their

approach to the world?

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Prompts

• Examples:

• Assist

• Asses

• Assign

• Compare

• Explain

• Reduce

• Revise

• Action Verbs!

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Common Factors Across Therapies That Are Associated With Positive Outcomes

Support Factor Learning Factor Action Factor

Catharsis & Trust Identification with therapist Positive relationship Reassurance Release of tension Structure Therapeutic alliance Therapist/client active participation Therapist expertness Therapist warmth, respect, empathy, acceptance, genuineness

Advice Affective experiencing Assimilation of problematic experiences Cognitive learning Corrective emotional experience Exploration of internal frame of reference Feedback Insight Rationale

Behavioral regulation Cognitive mastery Encouragement of facing fears Taking risks Mastery efforts Modeling Practice Reality testing Success experience Working through

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Support factors are correlated with establishing a counselor-client relationship. Learning and Action factors are correlated with treatment. Lambert, M. J., & Bergin, A. E. (1994). The effectiveness of psychotherapy. In A. E. Bergin & S. L. Garfield (Eds.), Handbook of psychotherapy and behavior change (4th ed., pp. 143-189). New York: John Wiley & Sons, Inc.

BUILDING BLOCKS OF TREATMENT PLANNING

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Building Blocks of Treatment Planning • Diagnostic Assessment

• Treatment Plan (Individualized Service Plan)

• Progress Note

• Termination Summary

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DIAGNOSTIC ASSESSMENT

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Diagnostic Assessment

• Client diagnosis and associated criteria/symptoms must be identified to select treatment goals, objectives and interventions

• Most manage care and private insurance companies consider treatment necessary and reimbursable when medically indicated

• The diagnosis, symptoms and severity are evidence of medically necessary treatment.

• Change in symptoms and alleviation of diagnosis are indicators or progress and/or termination (e.g., doctor will be reimbursed for treating cancer if the doctor document symptoms of cancer. Doctor will not be reimbursed for cancer if documenting symptoms of heart disease).

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Diagnostic Assessment

• Frequency: Admission and update every 90 days • Purpose

• Identify symptoms, diagnosis, strengths, limitation, needs, abilities, treatment preferences, level of adaptive functioning, psychosocial history, determine appropriate level of care

• Assessment Considerations: • Presenting problem, service needs and preferences • Diagnostic Criteria • Lethality assessment • Social history relevant to treatment including: employment and/or school history;

community involvement, interests and supports; history of involvement with the legal system; role of religious practices in the person’s life; description of current living arrangements, ethnic and cultural influences; developmental history, and use of alcohol and/or drugs

• Mental status examination • Considerations of special needs and additional services • Health/medical history. • History or indications of abuse, neglect or violence • Current or previously used medications, including allergies, effectiveness, side

effects or adverse reactions. • A summary of assessment information that includes a DSM-V diagnosis

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TREATMENT PLAN

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Treatment Plan

• Frequency: Second session and update every 90 days

• Typically include:

• Measurable goals that address the client’s strengths, skills needed and natural supports

• Measurable treatment objectives with a time frame for achievement that identifies the therapeutic intervention, frequency, service and the provider responsible for service delivery

• Goals and objectives that relate to needs, preferences and obstacles identified in the diagnostic assessment.

• Other agencies involved in treatment, when applicable

• Transition/discharge planning

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SMART Goals

• Specific – concrete, use action verbs

• Measureable – Numeric or descriptive, quantity and quality

• Attainable – appropriately limited in scope, feasible

• Results-oriented – Measures outputs or results, may include accomplishments

• Timely – Identifies target dates, includes interim steps to monitor progress

From: Paylo, M. J., & Kress, V. E. (2015). Developing Comprehensive Treatment Plans. In. V. E. Kress and M. J. Paylo (Eds.), Treating those with mental health disorders: A comprehensive approach to case conceptualization and treatment. (1st ed., pp. 1-24). Upper Sadler River, NJ: Pearson.

EXAMPLE: Decrease symptoms of depressed mood (sadness, loneliness, loss of interest, worthlessness) from an “8 – depressed mood impacts my life all day/every day” to a “6 – depressed mood impacts half of my day/ever day” one a scale of 1-10 (10= most severe) in the next 90 days.

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PROGRESS NOTE

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Progress Note

• Frequency: During or following session/meeting with client

• Typically include: • Date of the service contact

• Time of day of the service contact, start/stop time, including a.m or p.m.

• Duration of the service contact

• Description of the activities of the service

• Therapeutic interventions

• Behavior and the response to the intervention of the person served and

• Progress toward treatment goal

• The progress note will be directly tied to the goals and objectives listed on the client’s current treatment plan (Golden Thread)

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TERMINATION SUMMARY

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Termination Summary

• Reason: • Reached treatment goals • No longer benefiting from services • Referred to another agency or level of care • Client discontinued services or involuntarily terminated

• Typically include: • Date of admission • Date of discharge • Date of last contact • Diagnostic criteria at admission. • Diagnostic criteria at discharge • Level of care and services provided during treatment • Client’s response to treatment, including progress in meeting treatment

goals and condition at discharge • Recommendations and/or referrals for additional treatment or other

services, and after care options. • Reasons for termination

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STAGES OF CHANGE

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Readiness for Change • The proper question is not, “Why isn’t this

person motivated?” but rather, “For what is this person motivated?”

• Instead of focusing on what the person doesn’t want to change – it’s best to focus on what the person does want to change.

(Miller & Rollnick, 2002)

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Transtheoretical Model

Transtheoretical Theory = How clients change naturally (on their own) without interference.

Counselors need to know what stage of change the client is in so that proper interventions can be applied

Stages of Change:

▪ Precontemplation

▪ Contemplation

▪ Preparation

▪ Action

▪ Maintenance

▪ Termination

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The Stages of Change

Source: http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.section.62561

No intention of changing behavior

Intends to change in the next 6 months, but may procrastinate

Intends to take action soon, for example next month

Has changed behavior for less than 6 months

Has changed behavior for more than 6 months

TREATMENT PLAN LANGUAGE

Stages of Change

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Precontemplative

• Goal: Consciousness raising/Increasing awareness • Examples:

• Assist client with increasing awareness of the costs and benefits of changing unhealthy behaviors that are escalating behavioral health symptoms

• Assist client with increasing awareness of behavioral health symptoms

• Assist client with increasing awareness of patterns of behavior

Adapted from: Kress, V. E., & Paylo, M. J. (2015). The Foundations of Treatment Planning: A Primer. In. V. E. Kress and M. J. Paylo (Eds.), Treating those with mental health disorders: A comprehensive approach to case conceptualization and treatment. (1st ed., pp. 1-24). Upper Sadler River, NJ: Pearson. Norcross, J. C., Krebs, P. M., & Prochaska, J. O. (2011). Stages of Change. In J. C. Norcross (Ed.), Psychotherapy relationships that work: Evidence-based responsiveness (2nd ed.,pp. 279-300). New York, NY: Oxford

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Contemplative

• Goal: Client self-evaluation • Examples:

• Challenge client to evaluate self-perception in relation to behavioral health symptoms

• Encourage client to identify ways that changing behaviors will impact current level of functioning

• Assist client with envisioning a future with deceased behavioral health symptoms


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Preparation

• Goal: Empowerment

• Examples:

• Assist client with identifying ways he or she can contribute to changing behaviors that interfere with personal goals

• Encourage client to identify strategies to increase control over behavioral health symptoms

Adapted from:


Norcross, J. C., Krebs, P. M., & Prochaska, J. O. (2011). Stages of Change. In J. C. Norcross (Ed.), Psychotherapy relationships that work: Evidence-based responsiveness (2nd ed.,pp. 279-300). New York, NY: Oxford

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Active

• Goal: Reinforce progress toward change • Examples:

• Assist client with identifying internal gratification achieved through positive changes

• Encourage client to narrate story reflecting changes made and influence on personal goals

• NOTE: Most treatment planners correlate with the active stage of change but language can be adapted to all stages of change


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Maintenance

• Goal: Preventing relapse

• Examples:

• Assist client with reviewing strategies to maintain decrease in behavioral health symptoms

• Assist client with identifying ways to be proactive in maintaining progress made toward goals

Adapted from:


Norcross, J. C., Krebs, P. M., & Prochaska, J. O. (2011). Stages of Change. In J. C. Norcross (Ed.), Psychotherapy relationships that work: Evidence-based responsiveness (2nd ed.,pp. 279-300). New York, NY: Oxford

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Changing Active Goals: Precontemplation • ACTIVE

• Goal: “Alleviate depressed mood and return to previous level of effective functioning”

• Objective: “Identify and replace cognitive self-talk that is engaged in to support” depressed mood

• Intervention: “Assist the client in developing an awareness of his/her automatic thoughts that reflect a depressogenic schemata”

Jongsma, A. E., & Peterson, L. M. (2006). The complete adult psychotherapy treatment planner. Hoboken, NJ: John Wiley and Sons, Inc.

• PRECONTEMPLATION • Goal: Increase awareness of depressed mood and patterns of unhealthy

behaviors • Objective: Identify examples of negative self-talk from literature and case

examples correlated with depressed mood • Intervention: Assist the client in developing an awareness of the connection

between thoughts and depressed mood in people diagnosed with depression

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Changing Active Goals: Contemplation • ACTIVE





• CONTEMPLATION • Goal: Identify symptoms of depressed mood • Objective: Identify impact of cognitive self-talk on depressed mood • Intervention: “Assist the client in developing an awareness of his/her

automatic thoughts that reflect a depressogenic schemata”

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Changing Active Goals: Preparation • ACTIVE





• PREPARATION • Goal: Identify symptoms and behaviors associated with depressed

mood • Objective: Identify ways cognitive self-talk impacts depressed mood • Intervention: Assist the client in identifying ways more positive self-

talk could impact mood

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Changing Active Goals: Maintenance • ACTIVE





• MAINTENANCE • Goal: Maintain current level of effective functioning absent of

symptoms of depression that cause clinically significant distress • Objective: Engage in ongoing positive cognitive self-talk that

supports a healthy level of functioning • Intervention: Assist the client in reviewing techniques to maintain

positive thinking

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Material Adapted from: • American Psychiatric Association (Eds.) (2013). DSM-5. Arlington, VA

: American Psychiatric Publishing .

• Barnhill, J. W. (Ed.). DSM-5 Clinical Cases. Arlington, VA : American Psychiatric Publishing .

• First, M. B. (2013). DSM-5: Handbook of Differential Diagnosis. Arlington, VA : American Psychiatric Publishing .

• Jongsma Treatment Planning Series: http://jongsma.com/

• Jongsma, A. E., & Peterson, L. M. (2006). The complete adult psychotherapy treatment planner. Hoboken, NJ: John Wiley and Sons, Inc.

• Kress, V. E., & Paylo, M. J. (2015). The Foundations of Treatment Planning: A Primer. In. V. E. Kress and M. J. Paylo (Eds.), Treating those with mental health disorders: A comprehensive approach to case conceptualization and treatment. (1st ed., pp. 1-24). Upper Sadler River, NJ: Pearson.

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Questions and Answers

Q & A

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treatment planning 101: a clinicians guide to objective ... sessions/aocc 2015... · a counselors...

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