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MENTAL HEALTH AND WELLNESS PROGRAM Meeting the Policy and Requirement Handbook (PRH) Requirements for Documentation Valerie Cherry, PhD.

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Presentation on theme: "MENTAL HEALTH AND WELLNESS PROGRAM Meeting the Policy and Requirement Handbook (PRH) Requirements for Documentation Valerie Cherry, PhD."— Presentation transcript:

1 MENTAL HEALTH AND WELLNESS PROGRAM Meeting the Policy and Requirement Handbook (PRH) Requirements for Documentation Valerie Cherry, PhD

2 Mental Health and Wellness Program Chapter 6.10, R3 2 Mental Health and Wellness Program Chapter 6.10, R3 General Emphasis (a) Assessment (b) Promotion, Prevention, and Education (c) Treatment (d)

3 Mental Health and Wellness Program 3 (a) General Emphasis  Early identification and diagnosis  Basic mental health care  Mental health promotion, prevention and education  Employee assistance program approach Short-term counseling with focus on employability Referral to center support groups Crisis intervention

4 4

5 Mental Health and Wellness Program Documentation 5  (b) Assessment  Social Intake Form Most recent was released via Information Notice November 16, 2012 Bottom date - October 2012 Review within 1 week Signed by CMHC Completed Copy or Original in SHR

6 Mental Health and Wellness Program Documentation 6  (b) Assessment Con’t  Assessments and Recommendations for Referred Students What should the Intake include? Reason for Referral Presenting Problem Mental Health History Chemical Health History Mental Status Exam Barriers to Employability and Strengths DSM Diagnosis, if applicable Education and Recommendations Referral to Reasonable Accommodation Committee

7 Mental Health and Wellness Program Documentation 7  (b) Assessment Con’t  Intake Assessments should be placed in MH section of SHR Progress Note Mental Health Intake Forms (DRG) Provide student with Mental Health Chronic Care Management Plan (MHCCMP) Student Fact Sheets and note in SHR Job Corps Information Notice “Updated Chronic Care Management Plans”, dated April 10, 2014  Flow Sheets for recording periodic monitoring visits for students with Schizophrenia, Bipolar Mood Disorder, and Depression

8 Mental Health and Wellness Program Documentation 8  (b) Assessment Con’t  MSWR or Medical Separations Progress Note in MH section What should be included? Clinical justification for the separation due to health needs beyond what can be managed on center. Sometimes you may be asked for a recommendation on mode of transportation and if an escort is needed. Resource: Medical Transfer, Separation, and Referral; Management of Student Injury and Death Under FECA/OWCP TAG

9 Mental Health and Wellness Program Documentation 9  (c) Mental Health Promotion and Education  1-hour CPP Presentation Curriculum Standing day of the week for new inputs  CDP and CTP Presentations Curriculum Maintain a folder/binder, or computer file with days and topics  Annual Center Wide Activity Maintain a folder/binder or computer file with information

10 Mental Health and Wellness Program Documentation 10  (c) Mental Health Promotion and Education Con’t  Clinical Consultation with CD (monthly), Mgt. Staff, and HWM Minutes  Coordination with other departments Keep file on specific trainings for Counselors and/or Residential Advisors. Include SGA, HEALs and other center departments with center wide activities and document in your file their participation in developing the activity.

11 Mental Health and Wellness Program Documentation 11  (d) Treatment  Short term with employability focus Document on progress note in MH section of the SHR How do we document employability focus in a note? Sample Progress Notes in DRG MHCCMP Student Fact Sheet

12 Employability Focus  Student was referred by counselor for acting out behavior in the classroom. Student has history of anxiety and expressed feeling stressed out on center and difficulty with peers. Refer for medication evaluation and return in 1 week.  Student was referred by counselor for acting out behavior in the classroom. Student has history of anxiety and expressed feeling stressed out on center and difficulty with peers. Introduced distress tolerance activity to increase awareness of feelings and how to express them in a more positive way. Student agrees to journal and will return in 1 week. 12

13 Sample Employability Progress Note 13 S = Student reports having difficulty sleeping in the dorm along with feelings of sadness and disinterest in center activities over past two weeks. Student states he is becoming increasingly irritable during the day. O = Student was generally anxious throughout the session with a flat affect. At one point became tearful and slightly agitated. Able to verbalize how current symptoms could become barriers to employment if not resolved. Denied any suicidal thoughts or past suicidal behavior. A = Student has been on center for two months and is experiencing adjustment issues which may be triggering an episode of depression. Shows moderate level of motivation to address symptoms, identify, and remain in program. P = Schedule next appointment for 3:30pm to begin short-term cognitive behavior therapy to address symptoms on center and provide strategies on how to handle emotions on center and in future work environment. Gave student sleep hygiene brochure and instructed to return to wellness if problems do not get better before next appointment. Refer to Counselor ’ s adjustment group, alert RA and Counselor to watch for behavioral changes over the week and refer back to health and wellness, if needed. Lastly, student given mindfulness exercises to practice over next week. CMHC, Ph.D. # 1010

14 Assess/Info Gather Psycho-education Motivational Interviewing Crisis Intervention Stress Management CBT/ACT Empathic Exploration Social Skill Training DBT/Mindfulness Decision Making Psychodynamic/Relational Other INTERVENTIONS FOR EMPLOYABILITY Indicate primary types of interventions utilized (Check all that apply). Describe in summary of session. Sample Progress Note 14 SUMMARY (Include how the session ties into employability or the work environment for the student) Session Phone contact Case Management/Consultation Other __________________________________________________ _____________________________________________________________________________________

15 Mental Health and Wellness Program Documentation 15  (d) Treatment Con’t  Collaboration with TEAP Minutes of meetings  Collaboration with CP - Psych Meds Note on chronological record or note in MH section of SHR Standing meeting with CP and/or Wellness staff  Collaboration with Counseling staff in developing and/or leading psycho-educational groups Schedule of groups on center provided by counseling If you referred student to group, should be indicated in the SHR- MH section If you are conducting a group, should be indicated in the SHR

16 Documentation of Case Conferences and CMHC Led Groups 16  Pre-printed adhesive labels that allow enough space for brief sentence update. Signed and dated Emotional Regulation Group Student was active in group and participated in deep breathing exercise CMHC, PhD. Case Management Meeting Student continues to attend anger mgt. group and is doing well. No further MH services needed at this time CMHC, PhD

17 Mental Health and Wellness Program Documentation 17  (d) Treatment Con’t  Regular case conferences between CMHC, Counselors, and other appropriate staff- Case Management Documentation of Case Management and Feedback Form (DRG) in SHR in MH section Progress Note in MH section  Referral to Off Center- Case Management Release of Information to exchange updates Work with Wellness staff to come up with system to document off center updates in the SHR  Written referral and feedback system- Case Management Use of Referral and Feedback Form (DRG) Provide feedback to the referral source at the bottom of form. Copy in SHR Follow-up on feedback at next case conference and document in SHR

18 Care Management vs. Case Management 18

19 Care Management 19  PRH requirement [PRH-6.10: R1, 4] states “students identified as having chronic health problems during the cursory or entrance physical shall be monitored as directed by the CP or other appropriate center health provider.”  What CMHC tasks are considered care management?

20 Case Management 20  PRH requirement [PRH 6.10 R3, d5] states “Information exchange through regular case conferences between the Center Mental Health Consultant, counselors, and other appropriate staff based on individual student needs.”  Case management requires communication among staff, monitoring, and follow up  We do not recommend the use of CIS by CMHCS

21 Chapter 5 and Training 21

22 Chapter 5 - Exhibit  Centers shall include, at a minimum, the following:  a. Five hours of annual training in adolescent growth and development for all staff. Topics could include effective communications, anger management, sexuality, suicide prevention, behavior management system, zero tolerance policy, appropriate staff/student boundaries, sexual assault prevention and response, sexual harassment and related social skills training, crisis intervention techniques, bullying prevention, violence prevention, and safety issues.

23 Best Practices that Make Assessors Happy!  Document, Document, Document Smartly!  Have documentation organized and available.  Include discussions on how emotions and behaviors impact employability with students and document in progress notes.  Include documentation in the file on students discussed and updated during meetings with counselors.  Consistently provide information back to the referral source with a copy easily found in the SHR.  Notation on Chronological Record in SHR  “May 1, See Note in MH Section” 23

24 In A Nutshell  SHR - MH Section  Social Intake Form  Referral and Feedback Form Specifics for Referral Source  Intake Assessment MHCCMP RAC  Employability Progress Notes  Case Management Notes On and Off site  Med-Check in Notes  Group Notes  Mental Health Promotion and Education Binder  CPP, CDP, and CTP Presentation Info  Documentation of center wide activity  Documentation of any staff trainings  Chronological Record  Document dates students receive services with corresponding note in MH section. 24

25 Regional Mental Health Specialists  Region 1  David Kraft, MD, MPH  Maria Acevedo, PhD (PR Centers  Region 2  Valerie Cherry, PhD  Region 3  Suzanne Martin, PsyD, MPH  Region 4  Lydia Santiago, PhD  Region 5  Helena Mackenzie, PhD  Region 6  Vicki Boyd, PhD 25


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