neal adams md mph ed diksa sc d sharon kuehn mhre being person-centered… mapping the road to...
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Neal Adams MD MPHNeal Adams MD MPH
Ed Diksa Sc DEd Diksa Sc D
Sharon Kuehn MHRESharon Kuehn MHRE
Being Person-Centered…Being Person-Centered…Mapping the Road to Mapping the Road to
Recovery, Resilience and Recovery, Resilience and WellnessWellness
Training ObjectivesTraining Objectives Describe the treatment Describe the treatment
planning process, elements and planning process, elements and criteria as a roadmap to criteria as a roadmap to recovery and wellnessrecovery and wellness
Identify how emerging new Identify how emerging new frameworks of person-centered frameworks of person-centered recovery, resiliency and recovery, resiliency and wellness differ from past and wellness differ from past and current practice to guide the current practice to guide the plan of careplan of care
Training ObjectivesTraining Objectives Join in partnership with the client/ Join in partnership with the client/
family, develop and prioritize family, develop and prioritize objectives, interventions and objectives, interventions and services that reflect client/family services that reflect client/family strengths, preferences, choices and strengths, preferences, choices and stage of changestage of change
Define key elements of Define key elements of documentation (including Medical documentation (including Medical Necessity) and properly document Necessity) and properly document the elements of the plan and services the elements of the plan and services provided provided
President's MH President's MH CommissionCommission
Goal 2Goal 2 Mental Health Care is Consumer and
Family Driven Recommendation 2.1Recommendation 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
HypothesisHypothesis Person-centered treatment plans can Person-centered treatment plans can
be a be a key leverkey lever of personal and systems of personal and systems transformative change at all levels:transformative change at all levels: Individual and family Provider Administrator Policy and oversight
Building a PlanBuilding a Plan
Request for services
Assessment
Services
Understanding
Goals
Objectives
Outcomes
Prioritization
Barriers
What Do People Want? What Do People Want?
Commonly expressed goals of persons Commonly expressed goals of persons servedserved
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
Serving Two MastersServing Two Masters
Person-centeredPerson-centered Recovery Community integration Core gifts Partnering Supports self-direction
RegulationRegulation Medical necessity Diagnosis Documentation Compliance Billing codes
Outcomes and GoalsOutcomes and Goals
UnderstandinUnderstandingg
Plan DevelopmentPlan Development
Acquired skill / Art formAcquired skill / Art form Not often taught in professional training Often viewed as administrative burden and
paper exercise Requires flexibility
Opportunity for creative thinkingOpportunity for creative thinking Integrates information about person Integrates information about person
servedserved Derived from formulation and prioritization Information transformed to understanding
Strategy for managing complexityStrategy for managing complexity
Service Plan Functions Service Plan Functions Specifies intended outcomes / Specifies intended outcomes /
transitions / discharge criteriatransitions / 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 Establishes role of person served and family in their own recovery / family in their own recovery / rehabilitationrehabilitation Assures that services are person-centered Enhances collaboration between person
served and providers
Service Plan Functions Service Plan Functions continuedcontinued
Identifies responsibilities of team Identifies responsibilities of team members--members--including person served and including person served and familyfamily Increases coordination and collaboration Decreases fragmentation and duplication Coordinates multidisciplinary interventions Prompts analysis of available time and
resources Provides assurance / documentation of Provides assurance / documentation of
medical necessity medical necessity Anticipates frequency, intensity, duration of
services Promotes culturally competent servicesPromotes culturally competent services
Service Plan Functions Service Plan Functions continuedcontinued
Supports utilization managementSupports utilization management Services authorization, communication
with payors and payment for services Allocation of limited resource
A Plan is a Road MapA Plan is a Road Map
Provides hope by breaking a Provides hope by breaking a seemingly overwhelming journey seemingly overwhelming journey into manageable steps for both the into manageable steps for both the provider and the person servedprovider and the person served
A E
B C D
“life is a journey…not a destination”
A plan is only as good as the A plan is only as good as the assessmentassessment..
Cultural ElementsCultural Elements Person / provider relationship Person / provider relationship
shaped by differences in culture and shaped by differences in culture and social statussocial status
Impact clinical encounterImpact clinical encounter Communication Rapport Disclosure Privacy Trust Power Dignity Respect
Importance of Importance of UnderstandingUnderstanding
Data collected in assessment is by itself Data collected in assessment is by itself not sufficientnot sufficient for service planning for service planning
Formulation / understanding is essentialFormulation / 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 narrativeRecorded in a chart narrative
Shared with person served
UnderstandingUnderstanding Identifies individual's and family’s Identifies individual's and family’s
strengthsstrengths Identifies stages of change/recoveryIdentifies stages of change/recovery It helps determine prioritiesIt helps determine priorities
Accounts for choice and preference Enables everyone to see the Enables everyone to see the
interrelationships in the person’s lifeinterrelationships in the person’s life It serves as the context for the planIt serves as the context for the plan It clarifies the order in which It clarifies the order in which
objectives need to be addressed – objectives need to be addressed – sequential or concurrentsequential or concurrent
FormulationFormulation
Makes assessment data meaningfulMakes assessment data meaningful Involves clinical skill Critical value added component of entire service
process Narrative summaryNarrative summary
A few paragraphs More than just a re-telling of history / facts
Provide synthesis, analysis, insight, hypothesisProvide synthesis, analysis, insight, hypothesis Can include diagnosis and rational
Becomes the basis of creating the planBecomes the basis of creating the plan Understanding the why leads to informed tactics
and success
The 9 PsThe 9 Ps
P P ertinent history ertinent history [[brief brief ]] P P redisposing factorsredisposing factors P P recipitating factorsrecipitating factors P P erpetuating factorserpetuating factors P P resent condition / presenting problemresent condition / presenting problem P P revious treatment and responserevious treatment and response P P rioritization by person servedrioritization by person served P P references of person servedreferences of person served P P rognosisrognosis
Vignette--CarmenVignette--Carmen
18 year old Latina18 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
Vignette Vignette continuedcontinued
Excellent studentExcellent 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
Vignette Vignette continuedcontinued
Recent crisisRecent crisis Acute physical distress Admitted to hearing a baby cry while at
school Reported feeling sad and blue
Referred to mental healthReferred to mental health Embarrassed and resistant First family member to seek MH services
Vignette Vignette continuedcontinued
Assessment with Latina provider in Assessment with Latina provider in SpanishSpanish 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
Vignette FormulationVignette Formulation IdentityIdentity
First generation Latina Bilingual
Explanation of IllnessExplanation 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 relationshipProvider relationship
Spanish preferred More open with Latina clinician
Vignette FormulationVignette Formulationcontinuedcontinued
Psychosocial environmentPsychosocial environment Lives with family, first generation Some degree of acculturation and distance
from parents difficult and painful
DiagnosisDiagnosis Consider possibility of culture bound
syndrome Susto
Possible depression with psychotic features Understanding her beliefs may be key to
treatment
Vignette FormulationVignette Formulationcontinuedcontinued
HypothesisHypothesis 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
GoalsGoals Long term, global, and broadly statedLong 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 servicesLife changes as a result of services Focus of alliance / collaboration Readily identified by each person
Linked to discharge / transition Linked to discharge / transition criteria and needscriteria and needs Should describe an end point of helping
relationship
Goals Goals continuedcontinued
Person-centeredPerson-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 typesThree types Life goals Treatment goals Quality of life / enhancement goals
Goals Goals continuedcontinued
Essential featuresEssential 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
Carmen’s Plan Carmen’s Plan
GoalGoal “I want to graduate from high school”
BarriersBarriers
What is keeping the person from their What is keeping the person from their goals?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 Challenges / needs as a result of a mental / alcohol and drug disordermental / alcohol and drug disorder
ObjectivesObjectives Work to remove barriersWork to remove barriers
Must be active and positive Culture of persons served shapes Culture of persons served shapes
objectivesobjectives Important to address culture bound barriers
Expected near-term changes to meet Expected near-term changes to meet long-term goalslong-term goals Divide larger goals into manageable tasks
risk of being too trivial or to grand Provide time frames for assessing progress Maximum of two or three per goal recommended
ObjectivesObjectives
Build on strengths and resourcesBuild on strengths and resources Essential featuresEssential features
Behavioral Achievable Measurable Time framed Understandable for the person served
Services are not an objectiveServices are not an objective
Objectives Objectives Appropriate to the setting / level of Appropriate to the setting / level of
carecare Responsive to the person’s individualResponsive to the person’s individual
disability, challenges and recoverydisability, challenges and recovery Appropriate for the person’s age, Appropriate for the person’s age,
development and culturedevelopment and culture ““Dead man standard”Dead man standard” ““The individual / family will …”The individual / family will …”
Changes in behavior / function / status Described in action words
Carmen’s Plan Carmen’s Plan
GoalGoal “I want to graduate from high school”
ObjectiveObjective Carmen will return to class attendance for 5
consecutive full days within a month as reported by Carmen / or support worker
InterventionsInterventions ActionsActions by person served, family, peers, by person served, family, peers,
staff and and the entire system of carestaff and and the entire system of care may include family, support network, etc.
Specific to an objectiveSpecific to an objective Cultural efficacy must be consideredCultural efficacy must be considered Availability and accessibility of services Availability and accessibility of services
may be impacted by cultural may be impacted by cultural factorsfactors
Six Critical ElementsSix Critical Elements
Interventions must specifyInterventions must specify Provider and clinical discipline Staff member’s name Modality Frequency /intensity / duration Purpose / intent / impact
Clarifies who does whatClarifies who does what Include a task for the client and/or Include a task for the client and/or
family, or other component of family, or other component of natural support system to natural support system to accomplishaccomplish
Carmen’s PlanCarmen’s Plan Sample interventionsSample 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
Review / EvaluationReview / Evaluation Reassess plan at clinically Reassess plan at clinically
appropriate intervalsappropriate intervals Determine effectiveness Re-evaluate appropriateness Input of person served / family essential
Plan revisionsPlan revisions Concerns / needs Formulation Goals / discharge Objectives Interventions / modalities Time frames and target dates
Common MistakesCommon Mistakes
AssessmentAssessment Do not use all available information
resources Not culturally appropriate / sensitive Not sufficiently comprehensive Lack adequate integration /
understanding of the person
Common MistakesCommon Mistakes
GoalsGoals Not global Not directed towards recovery Not responsive to need Not strengths based Too many
Common MistakesCommon Mistakes
ObjectivesObjectives Don’t support the goal Not measurable or behavioral Interventions become objectives Not time framed Too many simultaneous objectives
Common MistakesCommon Mistakes
InterventionsInterventions Purpose not included Frequency, intensity, and duration not
documented Too few Don’t reflect multidisciplinary activity
““If you don’t know where you If you don’t know where you are going, you will probably are going, you will probably
end up somewhere else.”end up somewhere else.”
Lawrence J. PeterLawrence J. Peter
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