Making Recovery Real: Planning, Providing and Documenting Person-Centered, Culturally Competent Services

1. Making Recovery Real:Planning, Providing and Documenting Person-Centered, Culturally Competent Services Module Six: Progress Notes Webcast

2. DOCUMENTING THE RECOVERY JOURNEY

3. Learning Objectives Identify the reasons for skillful progress notes related to PCP, Cultural Competence and Accountability. Learn the basic rules and principles of writing progress notes. Understand billing codes. Identify non-billable services.

4. The Value of Progress Notes A record of the consumer�s recovery journey. A way to facilitate communication and coordination.

5. Progress Notes and Accountability Progress notes are part of a legal document � the chart. The chart can be subpoenaed. Progress notes are the basis for knowing what was done, by whom and when. Make sure you include consultations, with other providers as well as your supervisor.

6. Progress Notes and the Legal System If it ain�t documented, it didn�t happen.

7. Progress Notes and Supervision Progress notes are used as a supervisory tool. Progress notes form a record of your work with client�s in their recovery. Supervisors use progress notes to see what you�ve been doing. Writing good progress notes is an essential professional skill.

8. Progress Notes and Billing Progress notes establish one component of the basis for medi-cal billing. Progress notes must refer back to the client plan Which goal/objective is being addressed?

9. Accountability for Billing Every note you write is potentially a bill to the Federal Government.

10. The definition of a progress note Progress Notes are a brief written description in the client record each time services are provided.

11. What do progress notes include? Name of client Date of service Location Time involved What services were provided Signature, including discipline

12. Progress Note Basics Every progress note must be legible. When you make a mistake, cross out with ONE LINE, write �error�, and write your initials. NEVER USE WHITE-OUT! Draw a line through any space left on a page.

13. Progress Note Basics Notes must accurately reflect the activity, location and time for each service Time includes Time spent in travel to deliver the service Client plan progress review for next steps Providing the service Documenting the service

14. Progress Note Basics Big Time = Big Note OR Adequate description in the note of what took so much time.

15. Progress Note Basics Notes must reflect services based on the current assessment and client plan. Notes billable to Medi-Cal must demonstrate the mental health need for providing services. Not all services are billable � and may still be exactly the right service to provide.

16. Integration in Progress Notes We need to write notes that demonstrate awareness of all three components: cultural competence, person-centered practice and accountability. Let�s look at these areas in relationship to billing or not billing for services.

17. Billable or Non-billable?

18. IV: Billable but not Culturally Competent or Person-Centered Celia is extremely fearful of going outside of her house. CM provided support and deep breathing strategies to assist her in getting to her appointment with her psychiatrist. Cultural/diversity context/construct of meaning has not been determined. No identification of Celia�s involvement in determining this intervention.

19. III: Not Culturally Competent, Person-Centered and Not Billable CM drove Celia to her appointment with her psychiatrist. No identification of a mental health service being provided. No identification of Celia�s particular barrier to getting there on her own. No identification of relevant cultural/diversity issues.

20. II: Culturally Competent, Person-Centered, but not billable Celia requested transportation to her psychiatrist appointment based on the unavailability of nearby family members. CM explored the reasons for this request. Celia explained that in her culture a woman does not go to the doctor alone and she is uncomfortable taking public transportation. CM drove Celia to her psychiatrist�s appointment.

21. I: Culturally Competent, Person-Centered and Billable Celia is extremely fearful of going outside of her house and concerned that she will miss her psychiatrist�s appointment. CM explored the reasons for this request. She has no nearby relatives and explains that in her culture a woman does not go to the doctor alone and she is too frightened to take public transportation. CM supported her in asking a roommate to accompany her to her appointment, and provided coaching on stress reduction skills to reduce her anxiety.

22. Best Practice: Quadrants I and II

23. Best Practice Documentation Requires thinking at all three levels. For a service to be billable, it requires identification of a mental health service. You must describe the mental health issue as you also document the cultural/diversity and person-centered elements of service delivery.

24. Things to Think About Have you examined your rationale for the services you�re providing? Show your thinking. �Maybe�s� could be �yes�.

25. Progress Note Basics Notes must not include other consumer�s names.

26. Progress Note Basics Document evidence of coordination and collaboration, e.g., referrals. Document any changes to the treatment and recovery plan. Include date of follow-up care, appointments. Include discharge information on progress note (or summary).

27. Progress Note Basics Write as if the client is looking over your shoulder. Using respectful and recovery-oriented language

28. Timeliness Best practice is to write the note as soon as possible after delivering a service. Standards of timeliness vary depending on county or agency guidelines. When notes are written late, �Late Entry� must be clearly written on the note.

29. Other Essential Facts about Billing Every service contact requires an individual note. EXCEPTION: Targeted case management: every service contact, daily or weekly summary

30. Progress Note Basics Match Game Right click and select �End Show� This will bring you to Normal View. Select Slide 33 and print that page. Draw a line to match the column on the left to the correct response on the right. When you�re done, return to Slide Show, �View show� mode. Right click and select �Go to slide�, choosing slide 32. Click on ANSWERS. From there, right click, select �Go to slide� and choose slide 34.

31. Progress Notes Basics Match Game

32. Categories of Billable Services* Assessment Targeted Case Management Rehabilitation Plan Development Crisis Intervention Group Rehab Collateral Medication support Individual and Group Therapy Family Therapy

33. Scope of Practice To use a service category, you must have the credentials necessary to legally provide that service. For example, to provide therapy, you must be licensed, registered or waivered staff/ trainee. Parts of assessment, such as diagnosis also require the qualifications listed above.

34. Service categories not included in this section of the training. Assessment, as it is covered in another module. Services performed by medical staff such as Medication Support.

35. Targeted Case Management Services provided for or on behalf of the client to gain access to needed medical, social, educational and other services. Referrals Finding resources Making appointments Discharge planning Placement services

36. Rehabilitation Services Rehab services are designed to provide assistance in improving, maintaining or restoring a client�s functional skills Daily living skills Leisure Grooming and personal hygiene Meal preparation Support resources Medication education

37. Rehabilitation Services Rehab skills are designed to (cont): Assist in developing skills that will improve the client�s movement towards recovery. Assist client in achieving personal goals in areas such as relationships, community living, wellness strategies.

38. Plan Development Services provided in the Development of the client plan Approval of the plan Monitoring progress of the plan

39. Crisis Intervention This code is used when an immediate intervention is needed to help the client deal with an unplanned situation or circumstance. Services are limited to the stabilization of the emergency. The time is limited to eight hours during any 24 hour period.

40. Individual, Group or Family Therapy Therapeutic interventions consistent with the client�s goals and which focus primarily on symptom reduction, assisting in the client�s recovery.

41. Group Rehab Working in a group setting, with more than one client, to provide rehabilitation services. Such services include, but are not limited to Relapse prevention Health and wellness Stress management

42. Collateral Contact with family and significant support persons in the client�s life, that supports the individual in better using services and creating a better understanding of the client�s mental illness.

43. Non-billable services Not everything that we do is billable. Non-billable services are valid, necessary and must be included in the chart. The important thing is to know when NOT to bill.

44. Non-billable services For example, supervision is not billable.

45. What�s Not Billable Travel time when client no-shows Leaving a phone message Leaving a note on the door Travel when no mental health service is provided enroute Assisting clients with academic assignments Generalized socialization activities

46. What�s Not Billable � cont. Personal care services done for individuals Vocational services that actually train for job duties Solely clerical activities

47. Not Billable � with an exception Writing a discharge summary is not billable UNLESS you are transferring the client to another service.

48. To Bill or Not to Bill Read each of the following statements. On a separate sheet of paper, write whether or not the service is billable. Then, for services that are billable, add in the correct service category. When you�re done, come back to this slide. To view the answers, click HERE. When you finish checking your answers, right click, select �Go to slide� and choose slide 54.

52. That�s it for now! You will be very well-prepared for