NYS Case Management Coalition Conference May 2, 2012

Presented by Valerie Way, LCSW-R

New York Care Coordination Program

Timeline for Transformation

The emerging health care environment is focused on…

Engaged Partnershi

ps with Consumers

Greater Accountabili

ty f0r Outcomes

Integrated

Physical/Behavioral Health

Care

Recovery Focused, Person-Centered

Practices

The whole perso

n

How do recovery plans fit in?Used as a meaningful tool for providers,

consumers, payers and oversight authorities

Supports integrated and coordinated care

Supports family/person-centered approaches

Clarifies medical necessity in documentation

Promotes resiliency and recovery

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Serving Two Masters

Person-centered• Recovery• Community

integration• Core gifts• Partnering• Supports self-

direction

Regulation• Medical necessity• Diagnosis• Documentation• Compliance• Billing codes

Outcomes and Outcomes and GoalsGoals

UnderstandiUnderstandi

ngng

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recoveryskillbuilder.com

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“It is very important and necessary for individuals pursuing mental health and addiction recovery to design their own road maps. This book will assist providers in understanding their role in the journey of developing and facilitating an individuals' road map through person-centered planning. “

-Wilma Townsend

“This toolkit can be useful for anyone – regardless of whether they have a psychiatric condition or an addiction. Everyone needs help at times setting goals, and figuring out what they want. This toolkit has some specific parts that are helpful to people with a mental illness or addiction, but could be really used by anyone.”

-Janis Tondora-Rebecca Miller-Kimberly Guy-Stephanie Lanteri

Yale Program for Recovery and Community Health© 2009

Request for services

Assessment

Services

Understanding

Objectives

Goals

Outcomes

Prioritization

Strengths/Barriers

Vital Competencies for Developing Recovery Plans

1.Person-Centered Practices

2.Medical Necessity

3.Phase of Change/Phase of Recovery

4.Recovery Plan Components (goal, objectives, interventions, etc.)

1. Person-Centered PracticesSee the individual as the expert in their lifeInclude significant others/key collateralsIdentify strengths, capabilities, interests,

preferences, needs, hopes and dreamsAre culturally and linguistically competentProvide a systematic way to align resources

and supports with the person’s goals

Person-Centered Practices“Important To”

Define what is important to the person

Use quotes whenever possible so the documentation clearly reflects their input

Define desired changes in terms of specific, observable behaviors

“Important For”Address issues of

health or safetyDefine objectives the

person needs to achieve to be a valued community member

Addresses willingness and motivation to invest in recovery

2. Medical NecessityDefinition: “The clear demonstration that there is a

legitimate clinical need and that the services provided are an appropriate response.” - Adams and Grieder, Treatment Planning for Person- Centered Care, 2005

Symptoms support diagnosis and lead to functional deficits/barriers in the person’s life.

Treatment/interventions target the functional deficits to reduce or eliminate the impact of the diagnoses.

5 Elements of Medical Necessity

1. Indicated: There is a diagnosis to treat.

2. Appropriate: There is a match between the interventions provided and the individual’s need.

3. Efficacious: The intervention has been proven to work.

4. Effective: The intervention IS working.

5. Efficient: Time and resource sensitive

3. Models of Change/RecoveryOhio Village Prochaska

& DiClemente

Stage of Treatm

ent

Treatment Focus

Dependent unaware

High risk/Unidentified or unengaged

Pre-contemplation

Engagement

•Outreach•Practical help•Crisis intervention•Relationship building

DependentAware

Poorly coping/Engaged/But not self-directed

Contemplation/Preparation

Persuasion

•Psycho-education•Set goals•Build awareness

IndependentAware

Coping/Self-responsible

Action Active Treatment

•Counseling•Skills training•Self-help groups

Inter-dependentaware

Graduated orDischarged

Maintenance Relapse Prevention

•Prevention plan•Skills training•Expand recovery

Stages of Change*Pre-contemplation: Unaware of the problem or do

not want to fix it.Contemplation: Beginning to think change might be

a good idea.Preparation: Readying themselves to do things

differently regarding the problem.Active Change: Doing things differently and is

actively working to fix the problem.Maintaining Change: Made significant

improvements and wants to keep things from going back to the way they were previously.

Relapse: Things have slipped back to the way they were before and the individual needs to reinvest in the process of change. (Relapse may or may not be a phase in the process.)

*Based on the work of Prochaska and DiClemente

4. Components of the PlanGoal

Strengths related to the Goal

Barriers related to the Goal

Objectives

Interventions/Services/Supports

Discharge Criteria

Key Points about GoalsGoals express the hopes and

dreams of the individual.

Goals identify the hoped-for destination to be arrived at through the services provided.

Goal development is an essential part of engagement and creating a collaborative working relationship.

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Common MistakesGoals

Not globalNot directed towards recoveryNot responsive to needNot strengths basedToo manyNot in the person’s own words

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Examples of Goals

“ I want to continue drinking without getting suicidal”

“I want to have better relations with my parents”

John will report satisfactory relationships with family members

“I will obtain LPN license.”

Tom will have a 50% reduction of depression symptoms

Identify Strengths• Abilities, Talents, Competencies, Accomplishments

• Values and Traditions

• Interests, Hopes, Dreams, Aspirations and Motivation

• Resources and Assets

• Unique individual attributes (physical, psychological, performance capacities, sense of humor, etc)

• Circumstances at home, school, work, or community that have worked well in the past

• Family members, relatives, friends, other “natural supports” in the community

• Cultural Influences

• Previous successful experiences*Adams/Grieder

Identify BarriersWhat keeps the person from their goals?

EnvironmentalIndividual qualitiesAreas needed for skill developmentIntrusive or burdensome symptomsLack of resourcesSelf defeating strategies/interestsCultural factorsThreats to basic health and safetySubstance use

*Adams/Grieder

What do Objectives do?Take into account the

culture of person served (what’s relevant).

Divide larger goals into manageable units of completion.

Provide time frames for assessing progress. 23

Key Points about Objectives In contrast to long-term goals, objectives must be stated in

behaviorally measurable language (action words).

They are time-limited and it must be clear when the client has achieved the established objectives.

Objectives should be responsive to diagnosis, stage of recovery, age, development and culture.

Objectives should capture the positive alternative to the current needs and challenges and work to remove barriers, build on strengths and address cultural issues.

Each objective should be developed as a step toward attaining the broad goal; they can be changed and updated as the plan is reviewed. Maximum of 2-3 per goal is recommended.

When all the necessary objectives have been achieved, the individual should have accomplished the goal successfully.

How to write Objectives

Subject

Verb/Action Word

What

When will it be done/timeframe?

How will it be measured?

Jason

will use

any of his three coping techniques to address anger with parents

at least once a week over the next month

as measured by family report log.

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RUMBA:Realistic, Understandable, Measurable, Behavioral, Achievable

ExampleTemplate

Common MistakesObjectives

Don’t support the goalNot measurable or behavioralInterventions become objectives

Not time framedToo many simultaneous objectives

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Examples of Objectives

Tom will identify unhappy feelings related to life circumstances which will not be fixed by medications. Within the next 6 months, Doug will self report being free from the distraction of symptoms of auditory and visual hallucinations and poor concentration for a period of 1 month.

John will use his humor to improve relations with his family. In the next 6 months, Sam will successfully use 3-4 identified coping strategies to manage his feelings of anger as tracked in his journal.

In the next 3 months, Tammy will utilize a WRAP plan to successfully identify and plan for early warning signs of suicidal thoughts.

Interventions are the things in our “tool box”

Interventions reflect what specific action clients, clinicians, family members, natural supports, etc. will take to address target objectives.

Interventions describe medical necessity. This is where you identify what service is being provided (things that we want to get paid for).

Interventions must specify: provider name and discipline, modality, frequency/intensity and duration, purpose/intent/impact.

There should be at least one intervention for every objective. Consider biological, psychological and social interventions as well as natural support systems.

If the objective is not accomplished after the first intervention, then new interventions should be added to the plan. Keep in mind readiness/interest level in making change.

Key Points about Interventions

The 5 W’s of InterventionsWho: Which member of the

team or support system will provide it.

What: Specifically what will be provided/done.

When: How often, how much time and what is the duration.

Where: Identify the location of the delivery.

Why: Identify the purpose of doing the action. Link the intervention back to the desired outcome.

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Common MistakesInterventions

Purpose/why not includedFrequency, intensity, and duration not documented

Too fewDon’t reflect multi-disciplinary activity

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Examples of InterventionsTom will attend weekly psycho-education group.

In the next month, Doug will gather information regarding 1-2 educational programs for obtaining his LPN.

John and his parents will spend 30 minutes each week for the next three months doing a family activity together to increase family relations.

Sam will meet with counselor each week and attend group 3 days a week. Therapist, Patti Dropp, CASAC will meet with Tammy once a week for 45 minutes over the next two months to discuss daily activity logs which monitor alcohol use and suicidal thoughts.

Putting it All TogetherGoal:

Is it in the person’s words?

Strengths and Barriers: Do they relate to identified goal? Are there barriers related to behavioral health symptoms?

Discharge Criteria: Does it clearly reflect when the person has completed this episode of

care?

Objectives: Do they meet RUMBA? Do they reflect stage of change?

Interventions: Do they meet the 5 W’s? Do they reflect where the person is at with their readiness to make

change?