Neal Adams MD MPH Diane M. Grieder, M.Ed

1. Neal Adams MD MPH Diane M. Grieder, M.Ed

2. �You�ve got to have a little love in your life and some food in your stomach, before you can hold still for some damn fool�s 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. What�s 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 Clubhouse�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 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 person�s 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 family�s strengths Identifies stages of change/recovery It helps determine priorities Accounts for choice and preference Enables everyone to see the interrelationships in the person�s 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 stage�some 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 afternoon�s 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 served�s / family�s words Easily understandable in preferred language Appropriate to the person�s 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. Carmen�s 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 person�s individual disability, challenges and recovery Appropriate for the person�s age, development and culture �The individual / family will �� Changes in behavior / function / status Described in action words

65. Carmen�s 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 member�s 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 person�s 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. Carmen�s 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 Don�t 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 Don�t 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 don�t know where you are going, you will probably end up somewhere else.� Lawrence J. Peter