Coastal Plains Community Center

1. Coastal Plains Community Center 2013 PROGRESS NOTE TRAINING

2. There are various types of clinical services provided by Coastal Plains staff. • A progress note is written for each service provided to a customer or their Legally Authorized Representative (LAR). • The documentation needs to be in a format that will follow clinical, regulatory, and business guidelines. • The progress note is to be “recovery” focused. Remember, the goal is to help a person have a reduction in symptoms and to live a full life!

3. Isn’t “Recovery” a word associated with substance abuse treatment and services? Yes, but…“recovery” in behavioral health services means… • the process by which people are able to live, work, learn and participate fully in their communities. • the ability to live a fulfilling and productive life despite a disability. • focusing on hope. • empowerment to help the person develop positive relationships, grow personally, develop the skills to handle the stressors and adversity that they will face, etc... • the person is not trying to get back to where they were before, but to develop new goals and work towards those goals.

4. Texas Resilience and Recovery (TRR) The rationale of recovery is to measure the degree to which care is focused on increasing the person’s ability to successfully cope with life’s challenges, on facilitating recovery, building resilience, and not just on managing symptoms.

5. THE GOAL IS TO INTEGRATE PERSON CENTERED PRACTICE, CULTURAL COMPETENCE & ACCOUNTABILITY! STEP 7: EVALUATING OUTCOMES. STEP 6: WRITING EFFECTIVE PROGRESS NOTES. DOCUMENTING THE RECOVERY JOURNEY STEP 5: DEVELOPING CLIENT PLAN GOALS, OBJ & INTERVENTIONS. STEP 4: CLIENT PLAN OVERVIEW: A ROAD MAP TO RECOVERY. STEP 3: FORMULATION: WRITING THE CLIENT STORY STEP 2: CONDUCTING AN ASSESSMENT: EVALUATING A PERSON’S OVERALL SITUATION TO CREATE UNDERSTANDING. STEP 1: CONCEPTUAL OVERVIEW: INTRODUCTION TO THE ESSENTIAL SKILLS COMPONENTS AND CORE VALUES. STEPS TO SKILLS MASTERY!

6. Recovery-focused Services and Progress Note Writing When providing services, then writing the progress note to go along with the services you provided – the services and supports should be: • Strength-based • Focused on what they (and their family) want out of services in regards to recovery • How the person wants to see their future • What is a priority to them (not what we think their priorities should be!) • Focused on services based on the current assessment and client plan. Of course, these services all have to be medically necessary, approved by licensed staff and based upon need.

7. So What Exactly is a Progress Note? • A progress note is a legal document. • Progress Notes are a brief written description in the client record each time services are provided. • The progress note is the most common form of documentation in the clinical record, it is also the most likely to cause problems for staff. • This is especially true the longer you provide services to someone. Generally, the more you know about an individual, the less you write. You tend to forget that not everyone knows what you know. You are writing with a history of personal interaction that the reader may not have.

8. We are going to address… • The main elements of a rehabilitation (Rehab) progress note • The main elements of both routine and intensive case management (CM) notes • How to describe the service and support, not just make a statement • Writing objectively • Including “clinical observations” • How to document a person’s progress • Writing a progress note that is “recovery focused”

9. Words 101 You will see the word(s): Customer Individual Client Consumer Person Served All of these terms are “acceptable” to refer to the person you are serving. What might be easier, and most appropriate is: To refer the person in your note by their name! After all, it is their name! And it is a note about them! Abbreviations… there are too many to go through, but make sure you use approved abbreviations and don’t make up your own.Frequent errors: gr does not stand for grandma; GM means Gross Motor, not Grandmother; in fact there is NO approved abbreviation for grandmother! Cl is not the approved abbreviation for Client and diff stands for differential, not different.

10. First we will address:REHAB PROGRESS NOTES! There are twelve (12) main elements required in a rehab progress note Just to keep you on your toes, the who, what, when & where are not exactly in order on the progress note template in the electronic note! 

11. 1. Who received the service (consumer’s name) 2. What they received (skills, case management, etc…) 3. When they received it (date of service) 4. How long they received the service for (begin & end time) 5. Where the service was provided (if service is “other” or “school” you need to specify the Specific Location in the note) 6. Specific service provided and/or skill(s) trained method of training used, customer’s responses to the training 7. Clinical observations (symptoms of MI observed and physical changes noted) 8. Progress and current status(progress towards objective and any pertinent info related to the treatment that occurred during the service) 9. New Need(s) Identified? __No ___ Yes If yes, what? (check no or yes and describe) 10. Pertinent informationthese are non-clinical observations but important information about what is going on 11. Next scheduled appointment(this is the next appointment with you, the trainer/QMHP-CS) 12. Who provided the service (Including: signature and credentials)

12. Who received the serviceThe consumer name (on billing strip) 2. What they receivedA description of the service provided – e.g. • Stress management - journaling. • Supported Employment Training – appropriate dress and hygiene • Relapse prevention – identifying early warning signs • Using medication effectively – making informed decisions about medications • Relationships – learning how to connect with people • Etc…

13. When they received itThe date the service was delivered 4. How long they received the service The amount of time it took to deliver the service (start and stop time) FYI: units of service are in 15 minute increments – this is 15 continuous minutes. Do not round up! Document the exact time of the contact

14. FYI!!! TRAVEL TIME IS NOT included as part of the service time!!! You cannot bill for the time you spent in the car with the person, even if you were talking about what is going on in their life!

15. 5. Where was the service provided? The location in which the service was provided (these are all choices in the billing section of the progress note) • Office • Home • Other REHAB NOTES: You MUST indicate the specific location of where services were provided within the note • Private doctor’s office • ICF/Hospital • Jail/Juvenile detention center • Community setting not otherwise specified (e.g. restitution center, jail or E.R. not booked or admitted) • School

16. 6.Specific service provided and/or skill(s) trained & method of training used • The note needs to indicate what skill(s) you addressed from the treatment plan, how it ties back to an objective, and… • How you provided the training • Did you model the skill and have the person repeat the skill? • Did you provide instructions and have the person follow each step? • Did you role play or rehearse the skill? • Did you break the information down into different components and work on one component at a time? (shaping) • Did you review material and use repetition? • Did you follow fidelity treatment requirements and reference the material and chapter (for adult and children)?

17. 7. Clinical observations • These are notations of what you observe is going on, clinically, with the customer. They can be in either layman or clinical terms. Remember, this is the clinical record and all observations need to be objective. • Some examples: • James stated that he was still hearing voices telling him he is bad. • Suzie continues to isolate herself from her family, refusing to leave her room except to use the restroom. • Bob is talking very fast (pressured speech) • Kenny was full of energy, he would not sit for longer than 2-3 minutes at a time during training and redirection to concentrate on task was repetitive. • Terri said she is not cutting, but observed multiple cuts on both arms when staff had her reach for game.

18. 8. Progress towards goal • Progress or lack of progress in achieving the treatment goal or objective • Do’s and Don’ts: • Do – state progress in measurable terms and relate it back to the goal or objective you worked on with the customer that day. • Do – report both progress or lack of progress towards the goal/objective. • Do – put the customer’s opinion regarding their progress towards goal and use “quotes.” • Do– look for progress – remember to break things down into “steps” and look for small accomplishments. Report incremental progress! • Do – give examples of why you think the person is making progress or not making progress. • Don’t – report “participated in today’s session” and think this is a progress report. • Don’t– write “progress noted” “good,” “fair,” “poor” and think this is a progress report – none of these brief statements are actual progress reports and they are not acceptable.

19. 9. New Needs Identified? New Needs Identified? ___ No ___ Yes If yes, describe: Staff must check yes or no! If they check yes, they must describe what the person’s needs are. Examples of Needs Marriage CounselingFood Clothing Medical treatment HousingElectricity Clothing for new jobHousehold Goods Spiritual CounselingWorking Plumbing Help getting GEDWheelchair ramp for home

20. 10. Pertinent Information • This prompt is a place to document: • Referrals you may have given based upon new needs • Non-clinical observations that are pertinent to the case. • Clinical issues that you didn’t address during the visit that might need to be addressed in the future. • Here are some examples: • Theresa was referred to the food bank and St. Thomas church for food. • Matt is still drinking beer; referred to CODA for treatment, Matt denied having a problem. • John’s electricity was disconnected today. He has contacted his electric company to make arrangements to pay the bill. • Sue has a dr’s appt. to see her specialist for hip pain next Tuesday. Prompted to tell doctor about her hx of pain medication addiction. • Joe will be moving to Aransas Pass next week. Case Manager has made arrangements to transfer case to the Rockport clinic. • Mark has an infected thumb, he was referred to the health clinic.

21. 11. Next Scheduled Appointment • This is the next scheduled appointment with you, the skills trainer. • The easiest way for people to remember their appointments with you is to have a designated day, time and place for the appointments. • Bob and QMHP-CS will meet next Tues at 9:00 a.m. at his home for skills training. • Sue and CSSP will meet next Wednesday at the public library at 1:00 p.m. for SE training. • Will meet with Johnnie at school library next Friday at 9:10 am.

22. 12. Who provided the service? • The signature and credentials of the staff or contractor providing the services. • Must use LPHA, QMHP-CS, CSSP, LVN • Check to make sure that your electronic signature has your credentials on it. If it does not, you need to contact the Authority Department immediately to address this issue! • If you are a Qualified Mental Health Professional-Community Services (QMHP-CS) you must include the “-CS” after the QMHP • Listing your degree alone (BA, BS, MA) is not sufficient for audit purposes!

23. The majority of the progress note elements are addressed in the top portion of the progress note (billing information) . • Elements2, 6, 7 and 8 (description, specific skills trained/method of training, clinical observation and response to treatment ) are the sections that give people the most trouble. • These four elements are the main components of the progress note. • There are progress note templates in Anasazi for many of the service codes. The prompts on the templates are designed to help staff address the required documentation elements for the service provided. Checking off an item on the template does not mean you explained how you did something or what you actually did.

24. Selecting an Intervention- Adults Illness Management and Recovery (IMR) is the evidence-based practice for Adults. The ten topics are: • Recovery Strategies; • Practical facts about mental illnesses; • Stress-Vulnerability Model and treatment strategies; • Building social support; • Using medication effectively; • Drug and alcohol use; • Reducing relapses; • Coping with stress; • Coping with problems and persistent symptoms; and • Getting your needs met by the mental health system.

25. “Required “ and “allowable” Children and Youth Treatment protocols in FY 2013 A “required” protocol must be provided as intended by the developer and in accordance with the performance contract and UM guidelines. An “allowable” protocol can be provided but is not a requirement. “Allowable” protocols during FY2013: • Trauma-Focused CBT • Parent-Child Psychotherapy (Dyadic Therapy • Nurturing Parenting • Seeking Safety (will be required in 2014) • Preparing Adolescents for Young Adulthood (PAYA)( will be required in 2014) • Supported Employment (for transition-age youth) • Supported Housing (for transition-age youth)

26. “Required “ and “allowable” Children and Youth Treatment protocols in FY 2014 “Required” treatment protocols in FY2014: Cognitive Behavioral Therapy, Aggression Replacement Techniques and Social Skills Training (START: includes ART and Skillstreaming), Barkley’s Defiant Child and Defiant Teen, Seeking Safety and Preparing Adolescent for Youth Adulthood. “Allowable” treatment protocols in FY2014: Trauma-Focused Cognitive Behavior Therapy, Parent-Child Psychotherapy (Dyadic Therapy), Nurturing Parenting, Family Counseling, Play-Therapy, Supported Employment and Supported Housing.

27. Selecting an Intervention – Child & Adolescents CBT protocols approved to treat children and youth: Cognitive Behavioral Therapy (CBT) • Coping Cat – used with children ages 7-13 to treat anxiety related disorders. • The Cat Project – used with children ages 14-17 to treat anxiety related disorders. • Taking Action – used with children ages 9-13 to treat depressive mood disorders. • Adolescent Coping with Depression Course – used with youth ages 13-17 to treat depressive mood disorders. • General Cognitive Behavioral Therapy – used to treat diverse disorders or specific behavior problems in children and youth.

28. Selecting an Intervention – Child & Adolescents CBT protocols approved to treat children and youth: Trauma –Focused CBT (TF-CBT) Can be used with children and youth ages 3-18 to treat children and youth with PTSD symptoms, depression, behavior problems, and other difficulties related to traumatic life experiences. Parent-Child Psychotherapy (Dyadic Therapy) Can be used with children ages 3-7 years old to support and strengthen the relationship between the child and caregiver as a vehicle for restoring the behavioral and social functioning.

29. Selecting an Intervention – Child & Adolescents Skills Training protocols approved to treat children and youth: Aggression Replacement Techniques: used to treat children and youth with anger issues, oppositional defiant behavior, conduct disorder, and delinquent behavior. Social Skills Training (Skillstreaming): used to teach essential pro –social skills to children and youth and focuses on “feelings” and is targeted towards children and youth with difficulties expressing and coping with feelings. The following books/manuals should be used for delivering the aggression replacement techniques and social skills training: • Aggression Replacement Training Manual • Skillstreaming: The Elementary School Child • Skillstreaming: In Early Childhood • Skillstreaming : The Adolescent

30. Selecting an Intervention – Child & Adolescents Skills Training protocols approved to treat children and youth Nurturing Parenting : provided to parents or caregivers of children and youth to treat abusive or neglecting parent-child dysfunctional interaction and develops caregiver’s pro-social skills that will help the functioning of the child and caregiver. Nurturing Parenting skills training protocols are: • Parent s and Their infants, Toddlers & Preschoolers – 16 sessions • Parents & Their School – Age Children 5-11 years • Spanish Speaking Parents and Their Children 4-12 years • Parents & Adolescents Barkley’s Defiant Child – a protocol for children ages 3-12 struggling with ADHD symptoms only or Disruptive Behavior Disorder without aggressive behaviors. Barkley’s Defiant Teen – a protocol for youth ages 13-17 struggling with ADHD symptoms only or Disruptive Behavior Disorder without aggressive behaviors.

31. Selecting an Intervention – Child & Adolescents Skills Training protocols approved to treat children and youth: Seeking Safety: provided to children and youth ages 13 and older that have both substance abuse issues and a history of trauma. Can be conducted in group and individual format. Preparing Adolescents for Youth Adulthood (PAYA) – a protocol for youth ages 14-17 facing issues related to transitioning from adolescence to adulthood. The six PAYA modules are: • Money, Home, and Food Management • Personal Care, Health, Social Skills and Safety • Education, Jobs Seeking Skills, and Job Maintenance Skills • Housing, Transportation, Community Resources, Understanding the law, and Recreation • Young Parents Guide • Household Management Activities Note: It is not required that the entire module be used with a single youth, nor is it required that all modules be provided to a single youth. Does not require a specific sequence of sessions.

32. Timeliness of Notes • For legal and economic reasons, accurate and timely documentation is a component of Quality of Care • Progress notes are to be written and final approved in 2 working days, as per TAC Title 25: Chapter 412, Subchapter G Division 3 Rule 412.326 • Use Collaborative Documentation when writing your note. Collaborative Documentation is the completion of individual or group encounter documentation within the confines of the clinical appointment with the individual present and engaged in the process of documentation development.

33. Rehab notes should explain: • What skill was taught and how the skill was taught:Include adetailed description of the provision of the service including the strategies as identified in the recovery plan • What did you do while providing the training? • How did you train? • Prompts that you will see on the Rehab note template: ___interactive teaching ___role playing ___modeling ___ material review ___repetition ___ shaping ___positive feedback ___other: _____ Remember to indicate which technique(s) you used during your teaching. You must also explain HOW you used the technique that you checked off. Some other techniques for training: Instructed by…, Review & Repeat, Rehearsed, Practiced, Broke down into steps

34. Overwhelmed?We hope not! Stop right here! Talk about the different training techniques that you know of and how to use them. Were you ever “taught” in school to provide “training” to people? How do you think you would like to receive training? How is “training” different than “counseling?”

35. Rehab Progress Note Templatesand their “service codes” with definitions

36. 317 Psychosocial rehab: Team members will provide coordination services and training to improve or maintain independent living, employment, independent housing and self-administration medication skills. Team members will also provide crisis intervention services as needed. Location of service, if other than home or office: _____ Specific skill trained on: _______________________ Instructional strategies used: ___interactive teaching ___role playing ___modeling ___material review ___repetition ___shaping ___positive feedback ___other --- or --- Coordination service provided: ___needs assessment ____treatment planning ___linking ___monitoring progress ___identifying barriers Review of Homework given: ____________________ Summary of activities of this event: ______________ Progress on recovery plan objective: _____________ Clinical Observations: ________________________ New needs identified? ___ No ___ Yes If yes, describe: Homework given:_________________________ Pertinent information: _____________________

37. Both Supported Employment and Supported Housing progress notes have similar prompts. Staff need to remember that the services are to focus on skills to reduce or manage symptoms that interfere with the person’s ability to: 313 SE: make vocational choices, obtain or retain employment (services may include: instruction in grooming, socially acceptable behaviors, training to improve concentration/task completion, use of public transportation and resources, interventions and supports to reduce behaviors/symptoms that interfere w/employment) 314 SH: obtain or maintain independent housing (services may include: training on home maintenance and cleanliness, problem solving w/landlords, maintaining appropriate interpersonal boundaries w/neighbors, supportive contacts to reduce or manage behaviors or symptoms that interfere w/housing Location of service, if other than home or office: _____ Summary of activities of this event: ______________ Specific skill trained on: _______________________ Review of homework: _______________ Instructional strategies used: ___interactive teaching ___role playing ___modeling ___material review ___repetition ___shaping ___positive feedback ___other Progress on recovery plan objective: _____________ Clinical Observations: _______________________ New needs identified? ___ No ___ Yes If yes, describe: Homework Given: ______________________ Pertinent information: _____________________

38. Are you ready for some practice? The next slide will be a video of a psycho-social rehab service. Take notes as you are watching the video. You will be writing a progress note afterwards. This is a visit with Russ after developing his treatment plan. He came into the office to visit with his case manager.

39. Video of PSR training

40. Time to write your first note. You have 15 minutes to write your PSR progress note. This is an individual project, not a group project. Remember to write the note as if you were the trainer. The customer’s name is “Russ” in case you forgot. Use the template given to you for psycho-social rehab!

41. Discussion Time Grade each other’s notes using the score sheet 1) Does the progress note document the service that was provided and was the service tied back to the treatment/recovery plan? 2) Does the progress note include clinical observations (the person's appearance, attitude, behavior, mood, thought processes and perceptions)? 3) Were needs assessed at the visit? Explain:

42. SERVICE CODE 316 – SKILLS TRAINING & DEVELOPMENT: Staff will provide training in stress reduction techniques, training to improve communication skills, pro-social skills, independent living skills, anger management skills, problem solving skills, assertiveness skills, social skills, skills for managing daily responsibilities, skills for managing symptoms, skills to utilize community resources, and skills to utilize acceptable leisure time activities Location of training, if other than home or office: __________ Summary of activities of this event:_____________ Specific skill trained on:_________________ Review of homework from last session: _________________ Instructional strategies used: ___ interactive teaching ___ role playing ___modeling ___material review ___repetition ___shaping ___positive feedback ___other Progress on recovery plan objective:__________________ Clinical Observations: _______________________ New needs identified? ___ No ___ Yes If yes, describe: Pertinent information: ___________________________ Homework given: Next Scheduled Appointment: __________________

43. SERVICE CODE 316 – SKILLS TRAINING & DEVELOPMENT continued… Staff will provide training in stress reduction techniques, training to improve communication skills, pro-social skills, independent living skills, anger management skills, problem solving skills, assertiveness skills, social skills, skills for managing daily responsibilities, skills for managing symptoms, skills to utilize community resources, and skills to utilize acceptable leisure time activities There is a 2nd part to this note that must be filled out if you are providing services to ‘kids’. It looks like this: If Youth and Family Services, you must also address: Topics/program objectives covered during session:________  ________________________________________________ Practice methods used: ___ modeling ___role playing ___rehearsal ___ other (describe)_______________________________________

44. 307 Parent Training: Staff will provide training to primary care giver or LAR to assist the child to learn stress reduction techniques, improve communication skills, pro-social skills, independent living skills, anger management skills, problem solving skills, assertiveness skills, social skills, skills for managing daily responsibilities, skills for managing symptoms, skills to utilize community resources, and skills to utilize acceptable leisure time activities Location of training, if other than home or office: ___________________ Name of primary care giver/LAR trained: _________________________ Review of homework from previous session: ______________________ Topics/program objectives covered during session: _________________ Summary of activities of this event: ______________________________ Specific skill trained on: ______________________________________ Instructional strategies used: ___interactive teaching ___role playing ___modeling ___material review ___repetition ___shaping ___positive feedback ___other Practice methods used: ___modeling ___role playing ___rehearsal ___other (describe) ____________________________________________________ Progress on recovery plan objective: ______________________________ Progress on reward/incentive program: _____________________________ Homework given: ______________________________________________ Clinical Observations: __________________________________________ Other pertinent information: ______________________________________

45. What is not a rehab billable service? • Rehab provided to someone who is not present, awake or participating in the service. • Services to people who are not eligible for services. • Services that are not documented correctly. • Services that are not on the person’s authorized recovery plan (except for crisis intervention). • Services in excess of the amount authorized in the rule (e.g. no more than: 2 hrs of med training; 4 hrs of PSR; 4 hrs of rehab counseling or psychotherapy; or 4 hrs of skills training per day)

46. Are you ready for more practice? The next slide will be a video of children’s skills training. Take notes as you are watching the video. You will be writing a progress note afterwards. You will have to listen carefully as this is a teenager named “Debra.” She is swinging her chair back and forth and talking softly.

47. Skills Training

48. Time to write your 2nd note. You have 15 minutes to write your skills training progress note. This is an individual project, not a group project. Remember to write the note as if you were the trainer. The person’s name is “Debra” in case you forgot. Use the template given to you for Skills Training.

49. So, what about Case Management? The main elements of documentation for Case Management are the same. • Who received the service (customer’s Name – on billing part of note) • Whatthey received (Type of Service) • When they received it (Date of Service – on billing part of note) • How long they received the service (Begin & End Time – on billing part of note) • Where the service was provided (Specific Location – on the billing part of note) • Consumer contacted CM for assistance with the following needs (this is where you note the needs assessment) • Referral(s) made/assistance given to address current need(s) • Action(s) required by customer to meet need(s) • Progress and/or Response to Service (not “client seemed happy with services” or “client thanked me for services”) • Clinical observations • Whoprovided the service (Including: Signature and Credentials)

50. What is a Medicaid billable Case Management Service? • It is a service provided by a QMHP-CS • It is a service provided in units of 15 continuous minutes (again, there is no rounding up of minutes – 14 minutes does not bill – but you still need to document the contact) • It is a face-to-face service with the customer • Assessing customer needs AND Linking to community resources