1. Treatment Planning Essentials: Skill Building for Clinicians Week 2: The Golden Thread & Assessment

2. Welcome Back! Review of last week Review of virtual classroom Discuss clinical supervision learning path Thanks for patience with the technology

3. Poll: Who’s in the Class 1. Social Workers 2. Psychologists 3. QI Specialists 4. Counselors 5. Other Professions

4. Real-life Audit Scenarios Proprietary and Confidential 4

5. Audit Results  Scenario:  During a routine payer audit, it was discovered that the program was providing medication management services to a client who met medical necessity; however, there was not a medication management goal or objectives on the Treatment Plan.  Outcome:  All medication management services were disallowed.  Cost:  $7,500 Proprietary and Confidential 5

6. Audit Results  Scenario:  QI department received a “tip” that there was credible evidence of fraud in a PHS program. The national QI team investigated and reviewed all charts open during the previous year.  Outcome:  It was discovered that the Clinical Supervisor failed to sign and date a significant number of treatment plans during the past year, rendering them invalid.  Cost:  $50,031.16 Proprietary and Confidential 6

7. Audit Results  Scenario:  State came to program to conduct annual Medicaid audit.  Outcome:  Treatment plan objectives were not specific or observable; interventions on treatment plans were not being provided; Treatment plan interventions did not have a frequency (ad hoc is not a frequency); client signatures on Treatment Plans were late (no documentation of refusal or unavailability)  Cost:  $14,000 Proprietary and Confidential 7

8. The Golden Thread of Documentation  References the “tying together” of clinical medical record documentation  Each piece of documentation flows logically from one to another so a reviewer can see the connection 1  The beginning of the thread is the beginning of the client’s story- The Assessment  Any kink or break in the thread means that we are not adequately telling our client’s story. It also means that we are subject to recoupments in an audit. 8 Proprietary and Confidential

9. Flow of the Golden Thread  Assessment must be coherent, cohesive and establish Medical Necessity, and it must identify symptoms and behaviors to be addressed in the Treatment Plan  The Treatment Plan addresses the problems and needs identified in the assessment. It also identifies the services the client will receive based on the needs identified during the assessment.  Each note will reflect the clinical interventions provided in order to help the client meet identified objectives. Progress Notes flow from the Treatment Plan by specifically reflecting progress towards the identified goals and objectives 2  IT IS GOLDEN – If accurately followed, documentation will support each decision, intervention and progress note. It contributes to a complete record of client care that is error-free and ready for reimbursement! Proprietary and Confidential 9

10. Common Errors that “Break” the Thread  Progress Notes that are missing the staff member’s clinical intervention- notes describe a play-by-play of what the client did but not what the staff did  Progress notes are missing progress towards objectives  Notes contraindicate Medical Necessity  “Canned” language and plans- All language (excluding group descriptions) must be unique and not cloned. Beware of sibling files!  Plans need to be related to achieving the objectives, not attending the next service. Proprietary and Confidential 10

11. Now Let’s Talk about the Beginning of the Golden Thread Assessment!

12. 75% OF THE EFFORT TO SOLVE A PROBLEM IS ATTAINING THE CORRECT FORMULATION OF THE PROBLEM -albert einstein

13. The Assessment: Formation Of the Alliance - Arnow et al., 2013 Bickman et al., 2012

14. Break Out Session What are important pieces of information that you gather in your mental health intake assessment?

15. Some Ingredients of Good Mental Health Assessment  Problem identification/clarification  Level of functioning  Consideration of CULTURE. (BOOM!!!!)  History (of problem, education, medical, employment, etc.)  Risk Assessment/Suicide Risk Assessment  Identification of symptoms  Strengths!!!!

16. Some Ingredients of Good Mental Health Assessment  Important patient characteristics  Readiness to change  Social support  Coping styles  Mental status  Treatment goals - Maruish, 2002

17. Some Myths About Suicide Myth: Asking about suicide would plant the idea in my patient's head. Myth: There are talkers and there are doers. American Psychiatric Association, 2004

18. Some Myths About Suicide Myth: If somebody really wants to die by suicide, there is nothing you can do about it. Myth: He/she really wouldn't kill themselves since ______. he just made plans for a vacation she has young children at home he signed a No Harm Contract he knows how dearly his family loves him American Psychiatric Association, 2004

19. Questions

20. Let’s Meet Your New Client

21. Group Work  Review the assessment in your break out groups  Have a conversation with your group so that you can begin to develop a treatment plan for Katniss

22. Homework  Go into the virtual classroom to the “quiz” in week 2.  You will have to complete the quiz by:  Identifying a problem statement  Identifying 1 goal  Identifying at least 3 objectives based on the goal and 3 intervention statements based on the objective  Submit your quiz no later than 6pm PST Thursday, May 21 st. Of note: Completion of this assignment is required for CE credit

23. Summary  The golden thread is very important. Any kink or break in the thread means that we are not adequately telling our client’s story. It also means that we are subject to recoupments in an audit.  Assessment is the beginning of telling the client’s story. This is where you begin the formation of the therapeutic alliance that can lead to great treatment outcomes and retention. There are some additional assessment tools that you can use to enhance your understanding of the client’s story (e.g., TAQS, WHODAS, etc.)  There are many important parts of the mental health/intake assessment. We must make sure to assess all areas. Let’s especially pay attention to culture, risk, and medical necessity.  You have a very cool homework assignment about a character in a very cool movie.

24. References American Psychiatric Association. (2004). Practice Guidelines for the Assessment and Treatment of Patients with Suicidal Behaviors. In: Practice Guidelines for the Treatment of Psychiatric Disorders Compendium, 2nd edition. pp. 835-1027. VA: Arlington Arnow, B.A., Steidtmann, D., Blasey, C., constantino, M.J. et al (2013). The relationship between the therapeutic alliance and treatment outcome in 2 distinct psychotherapies for chronic depression. Journal of Consulting & Clinical Psychology, 81(4), 627-38. Bickman, L., Vides de Andre, A., Atahy, M.M., Chen, J.I., etl al (2012). The relationship between change in therapeutic alliance ratings and improvement in youth symptom severity: Whose ratings matter most? Adm Policy Mental Health. Maruish, M.E. (2002). Essentials of Treatment Planning. Wiley