A New Direction… - MTM Services by yurtgc548

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									A New Direction…
          Leading the Way!

      NYSCRI Pilot Study
  “Train the Trainer” Session
        March 2, 2010

                                1
          Project History

3/02/10        Presented by Robin Krajewski   2
                  Historical Overview
 Spring 2006 = Nassau County Risk Management Committee established
  due to increased corporate compliance demands
 June 2006 Meeting with Robin Krajewski, Long Island Field Office Director,
  and Risk Management Committee to discuss Ohio SOQIC initiative
 Fall 2007 = NYSOMH Commissioner, Michael Hogan, expresses support for
  a pilot Long Island Regional Pilot Project
 MTM Services Go-To-Meeting presentation and Committee agreement to
  seek Coalition member agreement and request project proposal
 Spring 2008 = Initial NYSOMH funding for a regional pilot
 Fall 2008 = MTM Services contracted
 Organizational structure and Project Teams developed
 March 2009 = Kick-Off Meeting to establish and charge Project Teams
 November 2009 = Project Phase One completed
 January 2010 = Project Phase Two Initiated
3/02/10                      Presented by Robin Krajewski                  3
          NYSCRI Project Goals
1. To develop and implement standardized
  clinical documentation data elements
  required by:

 Applicable funders
 Federal & State regulatory authorities CMS,
  NYSOMH, OASAS)
 National accreditation organizations (TJC, CARF,
  COA)
3/02/10              Presented by Robin Krajewski    4
       NYSCRI Project Goals (Cont)
2. To support a clinical record that will:
 Promote person-centered treatment
 Provide timely and cost-effective provider support
     for corporate compliance
 Support & enhance clinical documentation of
     Medical Necessity
 Promote transition, over time, from paper
     documentation models to Electronic Medical
     Records (EMR).
3/02/10                Presented by Robin Krajewski    5
NYSCRI Initiative Operational Structure
                              Long Island Behavioral             NYSOASAS
           NYSOMH                Health Coalition




                          QMC - Quality Management Council




                                    Standardized                Consumer/Family
      Compliance Review                                        Advocates Advisory
            Team                 Documentation Team
                                                                   Committee




3/02/10                         Presented by Robin Krajewski                        6
NYSCRI – Quality Management Council Team Members
     QMC Member             Affiliation
     Alexis Gadsden         Outreach Project
     Anita Fleishman        Pederson-Krag Center
     Barbara Bartell        CNGCS
     Cari Besserman         Pheonix House
     David Bloomberg        SCDCMHS
     Denis Demers*          Catholic Charities
     Doug Drew              OMH
     Harleen Ruthen         NCDMHCDDDS
     Herb Cohen             Family Service League
     Herb Ruben             Peninsula Guidance Center
     Lisa Lite-Rottmann     OASAS
     Marge Vezer            SAIL
     Pat Fogarty            Maryhaven
     Patricia Hincken       Long Beach Medical Center
     Philip Mickulas        Family & Children Assoc.
     Robin Krajewski*       OMH
     Ron Kaplan             FEGS
     Rosemary Dillon        Central Nassau
     Steve Greenfield       FREE
     Tom White              OMH

3/02/10                   Presented by Robin Krajewski   7
          NYSCRI – Compliance Review Team Members
  CRT Team Member                    Affiliation
  Carol Bond                         OMH LIFO
  Melena Bowling                     Maryhaven
  Joan Cassara                       Pederson-Krag Center
  Ken Corbin                         South Oaks
  Karen Dolecal                      SCDCMHS
  Judith Doria                       Central Nassau Guidance Center
  Michael Hoffman                    OMH LIFO
  Kristen Lott                       FREE
  Dora Lupo                          NCDMHCDDDS
  Nancy Manigat - Facilitator        Family & Children’s Association
  James McQuide - Resource           NYS OMH
  Cynthia Nye                        Family Service League
  Diana Reed                         OASAS
  Bob Savitt                         North Shore University Hospital
  Tom Schmidt                        SCDCMHS
  Mary Silberstein                   OASAS
  Frank Tardalo                      OASAS

3/02/10                         Presented by Robin Krajewski           8
 NYSCRI – Standardized Documentation Team Members

1. Assessment Group
               Name                                  Affiliation
Gaylene Pandolfo               OMH LIFO
Jeff Steigman*                 Pederson-Krag
Leslie Kizner                  FEGS
Maria Malonowski               Hispanic Counseling Center
Omayra Perez                   SSCGC
Patricia Hartley               Pederson-Krag
Scott Burzon                   SCDCMHS
Sherri Kaplan                  Central Nassau Guidance Services




 3/02/10              Presented by Robin Krajewski                 9
NYSCRI – Standardized Documentation Team Members
2. Individualized Action Plan Group
                 Name                                                Affiliation
Anu Arnold                                      FREE
Christine Buckley                               Mercy Medical Center
Christine Santangelo                            CNGCS
Jim Dolan                                       NCDMHCDDS
Judy Adams                                      OASAS Long Island Field Office
Elizabeth Weinbaum                              Concern for Independent Living, Inc.
Loren Campbell                                  Family & Children’s Assoc




 3/02/10                              Presented by Robin Krajewski                     10
NYSCRI – Standardized Documentation Team Members

3. Progress Note Group
               Name                                     Affiliation
Pam Rice, Lead                     Mental Health Association of Nassau County
Susan Steinhardt                   Options for Community Living
June Newill                        Maryhaven Center of Hope
Joe Chelales                       OASAS
Rosemary Sanchez                   Pederson Kreg




 3/02/10                 Presented by Robin Krajewski                           11
           NYSCRI – Consumer/Family Advocates
           Advisory Committee Team Members

CFAAC Member        Affiliation
Barbara Roth        NAMI Long Island Regional Council
Douglas Drew        NYS OMH Long Island Field Office
Barabara Tedesco    Mental Health Association of Nassau County, Inc.
Jesse Smith         Hands Across Long Island, Inc.
Donna Classi        Hands Across Long Island, Inc.
Lou-Ann Rinde       FEGS - LIFE Program
Deb Mayo            NAMI of Central Suffolk




3/02/10                  Presented by Robin Krajewski                  12
               NYSCRI – Contact Information
    Pilot or Form Questions: Dr. Jeff Steigman –
            jsteigman@pedersonkrag.org

   Evaluation Questions: Sherri Kaplan, LCSW –
           skaplan@centralnassau.org

          Web Site Questions: Scott Lloyd –
                 MTMScott@aol.com
3/02/10                Presented by Robin Krajewski   13
           Medical Necessity
           Documentation and Linkage

            Presented by:

            David Lloyd, President
            M.T.M. Services and Consultant for the
            National Council for Community Behavioral Healthcare




                          Presented by David Lloyd
3/2/2010                                                           14
                             President of MTM
             Medical Necessity
           Documentation Linkage
• Audit outcomes by the Office of Inspector
  General have provided excellent guidance
  regarding what is needed to demonstrate initial
  and on-going Medical Necessity

• Move to “tracer” model of review provides
  increased emphasis on quantitative and
  qualitative soundness versus just quantitative


                     Presented by David Lloyd
3/2/2010                                            15
                        President of MTM
  OIG Audit Notification Letter for MHCs
            in Illinois - 12/05




                 Presented by David Lloyd
3/2/2010                                    16
                    President of MTM
  Five NYSCRI Documentation “Golden Thread”
               Linkage Processes
     Five major linkage processes are built into the standardized
     NYSCRI form documentation system to support compliance with
     qualitative reviews.
1.   Comprehensive Assessment (CA) – Identifies Treatment
     Recommendations/ Assessed Needs
2.   CA Updates – Identifies New Treatment Recommendations/
     Assessed Needs
3.   Individualized Action Plan (IAP) – Links goals to specifically
     numbered Treatment Recommendations/Assessed Needs
4.   IAP Review/Revision - Links goals to specifically numbered
     Treatment Recommendations/Assessed Needs and/or changes in
     Objectives, Therapeutic Interventions, Frequency, Duration and/or
     Responsible Type of Provider.
5.   Progress Notes – Links interventions being delivered to specific
     Goal(s)/Objective(s) and identified client response and
     outcomes/progress towards Goal(s)/Objective(s).

                             Presented by David Lloyd
3/2/2010                                                            17
                                President of MTM
      Purpose of Comprehensive Assessment in
         Medical Necessity Linkage Funding
                   Requirements
• Crucial in determining the DSM or ICD diagnosis
• Assessment of symptoms, behaviors, and
  skills/abilities needs – all three areas within one
  assessment
• Documents support for assessed needs that will serve
  as the basis for identifying treatment
  recommendations
• Documents prioritize Treatment Recommendations/
  Assessed Needs to serve as the basis for
  Goal(s)/Objectives, Ordered Therapeutic Interventions
  and Services in the IAP
                      Presented by David Lloyd
3/2/2010                                              18
                         President of MTM
    Primary Purpose of CA in Medical
    Necessity Linkage Requirements
• The Comprehensive Assessment provides an
  opportunity for clinician to list the identified
  treatment recommendations/ assessed needs of
  the person (based on assessment of all three
  areas - symptoms, behaviors and skills/abilities
  needs) as evidenced by information gathered that
  supports each assessed need (i.e., Anger
  management as evidenced by anger at spouse,
  parents, boss and co-workers).

                    Presented by David Lloyd
3/2/2010                                         19
                       President of MTM
      CA Treatment Recommendations/
              Assessed Needs




3/2/2010                          20
           “Living” Comprehensive
               Assessment Tool
• While receiving services persons may experience
  other issues or have symptoms indicating an
  additional mental health and/or substance abuse
  need or concern that needs to be addressed
  through treatment

• Important to complete a CA Update form to
  make sure that new need is documented as an
  “assessed need” and incorporated into support
  for Goals/Objectives in the IAP

                   Presented by David Lloyd
3/2/2010                                          21
                      President of MTM
    “Official Diagnosis” Location
• Official Diagnosis for the person is located
  (“Housed”) in the CA or in subsequent CA
  Updates
• Need to reconcile in a CA Update a change
  in Diagnosis by Psychiatrist recorded in
  either a Psych Evaluation or a
  Psychopharmacology Progress Note


                  Presented by David Lloyd
3/2/2010                                     22
                     President of MTM
           Individualized Action Plan and Medical
              Necessity Linkage Requirements
 • Treatment Recommendations/Assessed Needs prioritized
   numerically (i.e., 1, 2, 3, etc.) in the initial Comprehensive
   Assessment (CA Update, Crisis Assessment & Plan and
   Psychiatric Evaluation) are linked to and become the core
   basis for each Goal in the Individualized Action Plan.
 • The linkage occurs by entering the Treatment
   Recommendation number, form date and checking the
   specific form type adjacent to the specifically numbered
   Goal.




                          Presented by David Lloyd
3/2/2010                                                        23
                             President of MTM
 Structured Progress Notes and Medical
    Necessity Linkage Requirements
• As the person served continues in treatment,
  he/she reveals/identifies additional personal
  information that enhances the original assessed
  information in the CA
• Progress Notes provide a critical linkage in the
  section entitled “New Issue(s) Presented Today”.
  This section accommodates the documenting of
  this new information and is illustrated below



                    Presented by David Lloyd
3/2/2010                                             24
                       President of MTM
 Structured Progress Notes and Medical
    Necessity Linkage Requirements
    This section provides two check box indicators - “None
    Reported” and “CA Update Required,” that are to be
    used as follows:
     1. If the client does not share any new
         information/issues at the session being
         documented, check “None Reported”.
     2. If the client shares new information/issues during
         the session that are assessed by the clinician to
         not constitute a continuing treatment need,
         record the information in this section of the
         Progress Note. CA Update is not required.

                        Presented by David Lloyd
3/2/2010                                                 25
                           President of MTM
 Structured Progress Notes and Medical
    Necessity Linkage Requirements
3. If the client shares an issue that can be resolved
   within the session of service, briefly identify the
   issue, indicated the interventions provided and the
   response in the appropriate sections of the Progress
   Note.
4. If the client shares new information/issues during the
   session that were not included in the original
   Comprehensive Assessment, (or an earlier CA
   Update), and the clinician determines that the
   information shared does constitute a continuing
   treatment need, the linkage requirements are:

                       Presented by David Lloyd
3/2/2010                                                26
                          President of MTM
             CA Update Process
• STEP 1
      – Indicate on the Progress Note in the “New
        Issue(s) Presented” section:
      – Person has self-reported new information
      – Check the “CA/IAP Plan Update Required” box
      – Note that the new information has been
        recorded on a CA Update and indicate the date




                       Presented by David Lloyd
3/2/2010                                            27
                          President of MTM
           CA Update Process
• STEP 2
      – Record information/issues provided by the
        client on the CA Update by checking the
        appropriate data element(s) from the initial
        Comprehensive Assessment (or an earlier CA
        Update) in the “Comprehensive Assessment
        Sections” and write the data element title and
        the information shared by the client in the
        “Update Narrative” section of the form.

                        Presented by David Lloyd
3/2/2010                                                 28
                           President of MTM
    Update Indicators Section of the
           CA Update Form




                Presented by David Lloyd
3/2/2010                                   29
                   President of MTM
           Using CA Update
• CA Update documents a change in
  Diagnosis
• CA Update should be placed in date order
  on top of the CA in the chart to provide
  the appropriate linkage to new services if
  information provided indicates new
  services are needed
• Provides an ongoing cumulative history of
  assessed needs of the person served


                  Presented by David Lloyd
3/2/2010                                       30
                     President of MTM
           CA Update Process Linked to
           Treatment Recommendations
• “Update Narrative” summary of the new
  information/ issues identified by the
  person served provides support for:
      – Change in diagnosis (if needed); and
      – Identifying new Treatment Recommendations/
        Assessed Needs (Next Slide) based on this
        information.


                      Presented by David Lloyd
3/2/2010                                         31
                         President of MTM
           Using CA Update Diagnostic Section




                       Presented by David Lloyd
3/2/2010                                          32
                          President of MTM
           Using CA Update Treatment
           Recommendations Section




                   Presented by David Lloyd
3/2/2010                                      33
                      President of MTM
           CA Update Process Linked to
           Treatment Recommendations
• STEP 3:
      – If the Treatment Recommendations/Assessed Needs are
        adequately addressed by the Treatment
        Recommendations/ Assessed Needs as identified in the
        original Diagnostic Assessment or earlier CA Updates,
        then check the box for “No Additional
        Recommendations Clinically Indicated” in the
        Treatment Recommendations section of the CA Update
      – Determine if existing Goal(s) and Objective(s) address
        the newly identified recommendations/needs.
      – If yes, use the Progress Note to identify the appropriate
        Goal and Objective and provide the interventions
        ordered.
      – If no, Step Four applies.
                           Presented by David Lloyd
3/2/2010                                                        34
                              President of MTM
    CA Update Process Linked to
           IAP Revision
• STEP 4:
      – If existing Goals, Objectives, Interventions,
        Services, frequency and provider types will NOT
        meet the client’s newly identified Treatment
        Recommendations/Assessed Needs, then link the
        newly assessed needs from the CA Update to an
        IAP Revision by checking the indicator in the
        “Change In IAP Required” field in the For Annual or
        Interim Updates section of the CA Update.



                         Presented by David Lloyd
3/2/2010                                                  35
                            President of MTM
  IAP Review/Revision Process Linked to
         Medical Necessity-Based
             Reimbursement
 • STEP 5:
       – If the newly identified information documented in
         the CA Update requires a change in the IAP, use
         the IAP Review/Revision form to update/modify the
         existing IAP which will preserve the linkage
         between newly assessed needs and any new
         therapeutic interventions.
                         Important Note:
If intervention provided is not linkable to a specific Goal/
Objective in a Individualized Service Plan (or IAP Review/
Revision), it is not adequately ordered and therefore, not
reimbursable.
                            Presented by David Lloyd
 3/2/2010                                                      36
                               President of MTM
    Link to Medical Necessity Based
       Reimbursement Summary
• Progress Notes provide an opportunity for specific
  linkages between the therapeutic interventions
  provided in the service visit/session to the IAP
  and/or IAP Review/Revision by requiring that the
  specific Goal(s) and Objective(s) being addressed
  in the service be clearly identified within the
  note.




                     Presented by David Lloyd
3/2/2010                                           37
                        President of MTM
Consumer, Families and
  Advocates Advisory
  Committee (CFAAC)
3/02/10   Presented by Douglas Drew   38
          Helping People Succeed!

             What is meant by Recovery




3/02/10             Presented by Douglas Drew   39
          Person-Driven Documentation
Why is Person-Driven Documentation Necessary?
      • It’s Effective:
           • Supports Personal, Meaningful Goal Acquisition – Success!
      • Engages the Individual
      • Heart-Brain Partnership
      • Encourages self-responsibility and allows the
        individual to direct (or learn to direct) and take
        ownership of health and life-oriented goals.
      • “It is becoming increasingly clear that a person-centered approach to care, in
        which the recipient of services is the driving force in the development of his or
        her individual plan, is the de facto standard of quality.”
           - Adams & Greider


3/02/10                            Presented by Douglas Drew                           40
          Person-Driven Documentation
    What Does “Person-Driven” Documentation Look Like?
     Reflects the Practitioner’s Value System.
     Concurrent Documentation Enhances Collaborative
      Relationship.
     Reflects the Aspirations of a Whole and Capable Individual.
     Reflects the real barriers people face.




3/02/10                    Presented by Douglas Drew                41
 What Does Person-Driven Documentation Look Like?
                     (literally)


          Engaging the Person Vs. an Illness

                       Role-Play:
          “Initial Screening & Assessment”

3/02/10               Presented by Douglas Drew   42
Recovery Oriented Documentation
Quality care respects the process of recovery and supports the
  purpose of mental health services to enable people to pursue
  personal life goals.

The following points describe some key dynamics of recovery:
•   All individuals have the capacity for personal growth and recovery from
    psychological trauma, disability and addiction.
•   Recovery is not only possible but expected.
•   Recovery can be sustained only if it connects to the individual’s personal history,
    life experiences, preferences and strengths.
•   It is impossible to know the timing or path of recovery in some else's life.
•   Professional expertise and systems can support or interfere with an individual’s
    recovery. The personal nature of recovery, however, can not be changed.

3/02/10                            Presented by Douglas Drew                              43
     What Does Person-Driven
Documentation Look Like? (literally)

          Engaging the Person Vs. an Illness

                     Role-Play:
                  “Progress Notes”

3/02/10               Presented by Douglas Drew   44
                         Person Centered
“It is becoming increasingly clear that a person-centered
   approach to care, in which the recipient of services is
   the driving force in the development of his or her
   individual plan, is the de facto standard of quality.
“The importance of choice, empowerment and
   engagement are recognized as keys to effective care
   and positive outcomes, not only in mental health and
   substance abuse but in general health care as well.”
Neal Adams’ and Diane Grieder’s book “Treatment Planning for Person Centered Care-The Road to Mental
   Health and Addiction Recovery”



3/02/10                                Presented by Douglas Drew                                   45
               Person Centered
 Continued:
 “A recovery-oriented system or program can be
  defined as having values of a person orientation (a
  focus on the individual who has strengths, talents,
  and interests, rather than the person as a case or
  diagnostic label)
 person involvement (the individual’s right to
  participate in all aspects of the service, including
  designing the individual plan, and implementing and
  evaluation services)
3/02/10              Presented by Douglas Drew           46
                Person Centered
• Self-determination/choice (a person’s right to
  make decisions and choices about all aspects
  of their treatment, such as desired outcomes
  and preferred services)

• Growth potential (given the opportunity and
    necessary resources, the inherent capacity of any
    individual to recover, grow, and change)”

3/02/10                 Presented by Douglas Drew       47
          Person Centered Language
Using strength-based language as opposed to
  deficit- based language is essential when using
  this approach. The following chart from
  Adams and Grieder illustrates this point.


1. Setting Recovery Goals: The “Art of Conversation”; December 2008



3/02/10                            Presented by Douglas Drew          48
          Person Centered Language




3/02/10           Presented by Douglas Drew   49
          Health in Body and in Mind

      “Overall Health is Essential to Mental
                      Health”

                                         -NASMHPD




3/02/10             Presented by Douglas Drew       50
          Health in Body and in Mind
• Recent data from several states have found
    that [individuals] with serious mental illness
    served by our public mental health systems
    die, on average, at least 25 years earlier than
    the general population.

3/02/10              Presented by Douglas Drew        51
          Health in Body and in Mind
Identified Problems:
• Increased Morbidity and Mortality Associated with Serious
   Mental Illness (SMI)
• Increased Morbidity and Mortality Largely Due to Preventable
  Medical Conditions
          • Metabolic Disorders, Cardiovascular Disease, Diabetes Mellitus
          • High Prevalence of Modifiable Risk Factors (Obesity, Smoking)
          • Epidemics within Epidemics (e.g., Diabetes, Obesity)
• Some Psychiatric Medications Contribute to Risk

• Established Monitoring and Treatment Guidelines to Lower
  Risk Are Underutilized in SMI Populations
3/02/10                        Presented by Douglas Drew                     52
          Health in Body and in Mind
SO WHAT CAN WE DO?
•   “We encourage clinicians to adopt a structured system for conducting and
    recording metabolic monitoring and to develop collaborations with family
    physicians, diabetes specialists, dieticians, and recreation therapists to facilitate
    appropriate medical care for antipsychotic [psychotropic]-treated patients.

•   “Clinicians should screen patients for metabolic disturbance, should track the
    effects of antipsychotic [psychotropic] treatment on metabolic parameters, and
    should facilitate access to appropriate medical care.

•   “Mental health systems need to incorporate monitoring protocols into standard
    care, promote collaboration with other medical disciplines, and dedicate
    resources for lifestyle management [education].”*

                               *Michael J Sernyak, MD, et al (Can J Psychiatry 2006;51:492–501)
3/02/10                              Presented by Douglas Drew                                    53
          “Yes, but what if…?”
• “The person does not have any goals they want
  to work on?”
• “We have to address the person’s harmful/risky
  behaviors with a treatment plan and they won’t
  agree to it?”
• “I see no strengths in the person?”
• “The person is not able or refuses to participate
  in planning?”
• “The individual does not want to take
  medication?”
3/02/10             Presented by Douglas Drew         54
             “Yes, but what if…?”
• The “Puzzle of Recovery” began as a workshop developed
  to portray, quite literally a picture of recovery that was
  creative, understandable, playful, and most importantly
  personalized. Thinking of a future life picture that was
  broken down into “puzzle pieces” like “poetry,” “hiking,”
  “friendship,” “college,” “my dog,” “reiki,” “meditation,”
  “volunteer work/work,” and more subject “pieces” like,
  “self-responsibility,” “self-esteem,” etc. allowed individuals
  to see a picture of a life that they might like to live and
  might be inspired to work towards. When Consumer Link
  put together their “Handbook of Recovery” several years
  ago, they used a variation of the “Puzzle” as an illustration.

3/02/10                  Presented by Douglas Drew             55
           “Yes, but what if…?”
Roadmap to Recovery
• The Roadmap to Recovery is a visual tool that the
  individual develops for themselves to “map” their
  journey of recovery. It can include detours and
  roadblocks (relapse, loss of job or housing), rest
  stops (rehabilitation programs, hospitalizations,
  respite care) road side assistance (recovery
  programs, community resources), a key (time
  frames, objectives) and an ultimate destination
  (goal).
3/02/10              Presented by Douglas Drew         56
                       In Conclusion:
Ultimately, person centered documentation uses tools and practices that:

• Assumes individuals can and do achieve personally meaningful goals.
• Respect & recognize the innate strengths & skills individuals possess.
• Provides self-directed services and supports.
• Fuels treatment with the goals and values of the individual.
• Encourages & empowers the individual to overcome obstacles.
• Addresses safety issues in a collaborative relationship between the
  individual and the provider.
• Teaches the individual to recognize and create their own options.
• Allows individuals to make, and grow from, their own mistakes.
• Enable individuals to pursue life goals independently!


3/02/10                       Presented by Douglas Drew                    57
Commissioner’s Message

          Michael F. Hogan, PhD.



3/02/10                            58
    Compliance Review
       Team (CRT)

3/02/10   Presented by Nancy Manigat   59
          Compliance Review Process
                  Compliance Review Team
• Composed of 16 Members
• Representing OMH, OASAS, LI Provider Organizations
• Divided Into 6 Workgroups:
      o   OMH/DOH
      o   OASAS
      o   Federal Medicaid / Medicare
      o   COA
      o   TJC
      o   CARF
3/02/10                     Presented by Nancy Manigat   60
Regulations and Standards
          Compliance Review Process
Compliance Review Team (CRT)
  Responsibilities
1. Develop a Compliance Grid
   – Identifying Required Behavioral Health
     Documentation Elements and Content for all
     Applicable Federal and State Regulations, and
     Accrediting Body Standards

3/02/10             Presented by Nancy Manigat       62
Compliance Grid Sample
           Compliance Review Process
Compliance Review Team (CRT) Responsibilities
2. Review all developed forms to ensure that they
   – meet all applicable regulations and standards
   – Provide Support for Demonstration of
           o Medical Necessity
           o Participation of Individual Served
           o Benefit to Individual Served


 3/02/10                      Presented by Nancy Manigat   64
          Assessments

3/02/10                 65
               General Comments
• Assessment forms were developed with
  various goals in mind including:
      – Making them as client(individual)/family focused
        as possible. Forms elicit engagement in the
        process and feedback from individuals/family (i.e.,
        response to recommendations for treatment;
        service preferences, what was helpful in past).
      – Recovery Oriented as evidenced by:
        Focus on strengths, prioritized needs, supports,
        barriers that need to be removed to address goals
3/02/2010                Presented by J. Steigman         66
            General Comments-cont’d
• To enhance clinical utility while finding the right
  balance with regard to the amount of detailed
  information sought (outside of compliance
  standards).
• To build in flexibility/increase ease of use -i.e.
  addendums as a companion to the Comprehensive
  Assessments. Addendums are utilized if there is a
  positive response to general questions within the
  Assessments.
3/02/2010             Presented by J. Steigman          67
                  Personal Information
• Completed at the time of initial contact with
  the person who is seeking services.
• Captures essential information including:
            Why individual is seeking services now/? Imminent Risk
            Demographics
            Contacts (including for Emergencies)
            If individual is currently involved in treatment elsewhere
            If currently taking psychotropic medications- and if so, how much
                medication is left?/who was the last prescriber?
            Legal Status
            Special Needs


3/02/2010                           Presented by J. Steigman                    68
                Personal Information
      Drug/Alcohol Use in the last month
      If referred out, where to and reason

• This form can be completed by support staff
  or clinical staff.
• The second page of the form was designed to
  capture necessary insurance information and
  allow for verification of such benefits.
  Similarly, it captures income and dependent
  information for self-pay clients.
3/02/2010                       Presented by J. Steigman   69
            Adult/Child & Adolescent
           Comprehensive Assessments
• Complete after the Personal Information form, as the
  individual enters services.
• The Comprehensive Assessments provide a standard format
  to assess mental health, substance use and functional needs
  of individuals served. This Assessment provides a summary of
  assessed needs that serve as the basis of Goals and Objectives
  in the Individualized Action Plan
• Used to capture relevant historical information.
• A qualified clinician will complete, or oversee the completion
  of, this form based upon face-to-face session with individual.


3/2/2010                  Presented by J. Steigman             70
                Addendums
• Substance Use/Addictive Behaviors
• Legal Status
• Legal Involvement and History Addendum
• Employment
• Military Service Assessment (for individual
  and one for significant others)
• Medical History and Assessment
  Questionnaire
3/02/2010          Presented by J. Steigman     71
            Addendums-Cont’d
• Mental Status

• Risk Assessment

• Communicable Disease Risk Assessment
  (OASAS programs)

3/02/2010           Presented by J. Steigman   72
Substance Use/Addictive Behaviors
           Addendum
• Used to capture current or past substance
  use/addictive behaviors.
• Provides for a structured, comprehensive
  assessment of addictive behaviors/substance
  use.
• Covers all the major classes of drugs, and
  alcohol.
3/02/2010         Presented by J. Steigman      73
Substance Use/Addictive Behaviors
       Addendum-Cont’d
• Includes a gambling screening and a section for “other
  addictive behaviors” (internet, shopping, pornography,
  food….).
• Obtains relevant relapse history information (attempts to
  abstain, longest period of abstinence, reasons/triggers for
  relapse).
• Denotes how substance use has impacted various life areas.



3/02/2010                Presented by J. Steigman               74
            Legal Status Addendum
• This addendum was developed to capture
  information related to the following potential
  arrangements involving an individual:
      – Representative Payee
      – Legal Guardian
      – Conservatorship
      – Special Needs Trust

3/02/2010              Presented by J. Steigman    75
      Legal Involvement and History
                Addendum
• To be completed when an individual is currently involved with, or
  has a history of interaction with, the legal system.
• Catalogued in the following way:
   – Problem Solving/Family Court Involvement (Problem
     Courts=Integrated Domestic Violence, Domestic Violence, Drug
     Treatment, Mental Health, Sex Offense, Youthful Offender
     Domestic Violence, and Community )
   – Assisted Outpatient Treatment (AOT)
   – Criminal (Non-Problem Solving) Court Involvement
   – CPS Involvement
3/02/2010                  Presented by J. Steigman               76
      Legal Involvement and History
            Addendum-Cont’d
• Collects relevant information including:
   – Name of Court (where applicable)
   – Reason for involvement
   – Status (current or past)
   – Contact information
• Questions whether legal status will influence treatment, or not (i.e.,
  urgency of legal situation, relationship between presenting
  condition(s) and legal involvement


3/02/2010                    Presented by J. Steigman                 77
            Employment Assessment
                  Addendum
• In the Comprehensive Assessments, employment
  status and a detailed work history is obtained.
• If individual would like help in finding employment,
  this addendum would be completed.




3/02/2010             Presented by J. Steigman           78
            Employment Assessment
              Addendum-cont’d
• Satisfaction with past jobs
• Skills, abilities, interests
• Past barriers to finding gainful employment
• Documents employment/educationalrelated needs
  individual wishes to pursue.
• Asks the provider to offer a summary statement with
  regard to individual’s functioning in different areas
  and how this may impact work ability.
3/02/2010             Presented by J. Steigman        79
            Military Assessments
• In order to make the necessary life saving changes in
  our system we must recognize and address several
  issues impacting service members and their
  significant others
• Our current methods are no longer sufficient, for
  example, we tend to ask for veteran status on
  intakes, and we therefore omit active duty, reserves,
  National Guard and those who had less than an
  honorable discharge
3/02/2010             Presented by G. Pandolfo        80
            Military Assessments
• In our children’s programs it is not uncommon to see
  veteran status checked “no, child is a minor”
• This method fails to identify children and families
  who are impacted by the cycles of deployment
• The Comprehensive Assessment will identify if the
  individual or a significant other has served in the
  United States Armed Forces. If “yes” providers will
  have the option to utilize either the Military
  Assessment or Military Assessment for Significant
  Others
3/02/2010            Presented by G. Pandolfo        81
            Military Assessments
• The Military Assessment and the Military
  Assessment for Significant Others are new
• Identify military servicemen and woman
• Identify military families
• Address immediate needs
• Safety Issues
• Clinical concerns
3/02/2010          Presented by G. Pandolfo   82
            Military Assessments
• The Military Assessment will assist clinicians
  with identifying:
• Physical health concerns as a result of service
• Traumatic Brian Injury Screen
• Military Trauma Screen
• Military Sexual Trauma Screen

3/02/2010           Presented by G. Pandolfo    83
            Military Assessments
• Social Contracts such as, “Did you have an
  unexpected Tour Extension?”
• Community, Social Supports, and Resiliency such as
  “Have your military experiences impacted your view
  of the world?”
• Sections for couples and families
• The Manual will assist with all sections including the
  Clinical Formulation section as well as providing vital
  linkage information
3/02/2010              Presented by G. Pandolfo         84
            Military Assessments
• The Military Assessment for Significant Others
  includes the impact of deployment, military trauma
  screen (PTSD can be trans generational)
• Section for couples which identifies infidelity and
  intimacy issues
• Section for children examines attachment and
  bonding issues
• Missed milestones such first steps or words,
  graduations, birthdays, etc.
3/02/2010             Presented by G. Pandolfo          85
   Medical History and Assessment
• Completed according to regulation and
  agency policy.

• Assesses current and past medical issues of
  the individual served.

• Sections of this form may be self-
  administered, but must be reviewed by a
  medical professional.
3/02/2010          Presented by J. Steigman     86
            Mental Status Exam
• This is a data gathering tool to assess current
  functioning (symptoms, behaviors, etc).
• This is a component of the comprehensive
  assessment, and Psychiatric Evaluation/PE Update-
  or, it can be completed as part of a stand-alone
  assessment or as part of an update.
• This form was designed as a template, or providers
  can write a narrative (ie., choice is given in
  Comprehensive Assessments).


3/02/2010            Presented by J. Steigman          87
            Risk Assessment Addendum
• Used to assess risk of harm to self or others as part
  of a comprehensive assessment, Psychiatric
  Evaluation or Update.
• Can be used when assessing risk at any particular
  point in time (as a stand-alone document).
• The form is:
     – A convenient way of assessing a number of risk factors
       that have been correlated with increased risk, including
       suicide and homicide risk
     – Is utilized when an individual endorses past or current risk
       factors
3/02/2010                   Presented by J. Steigman                  88
Risk Assessment Addendum-Cont’d
      – Enables one to document that a thorough risk
        assessment has taken place.

      Note: This form does not substitute for clinical
       judgment as to how severe the risk may be and
       what intervention is needed to reduce the risk. In
       attempting to gauge and document the level of
       risk, clinical judgment must be used as this form
       does is not scored or validated.

3/02/2010                Presented by J. Steigman           89
            Communicable Disease Risk
                 Assessment
• Required for OASAS licensed programs; completed in
  concert with the comprehensive assessments.
• Optional for other programs
• Assesses current and past risk behaviors in this area.
• Completed by individual served/or according to
  agency policy.



3/02/2010             Presented by J. Steigman         90
Adult/Child-Adolescent CA Update
• Developed to save time and effort while effectively
  capturing necessary info.
• Used to update information in Comprehensive
  Assessment.
• Used whenever there is a substantial change in
  person’s status and/or according to regulation or
  agency policy.
• Completed based upon a face-to-face session with
  an individual (and by qualified staff).
3/02/2010             Presented by J. Steigman          91
            Initial Psychiatric Evaluation
• Completed by a psychiatrist or Nurse Practitioner in
  Psychiatry (NPP).
• Completed as part of the assessment process.
• Used to assess the psychiatric service needs of the
  individual.
• Components of this evaluation are included in the
  comprehensive assessments. Medical staff are
  expected to review the Comprehensive Assessment
  when available.
3/02/2010              Presented by J. Steigman          92
       Psychiatric Evaluation Update
• Used to update information from the time of the last
  Psychiatric Evaluation/Update was completed
  (interval history).
• Used whenever there is a substantial change in
  person’s status; according to regulation or agency
  policy; or, when there is a need to document current
  psychiatric functioning (i.e.,
  application/recertification for ancillary service).
• Completed based upon a face-to-face session with
  an individual.
3/02/2010            Presented by J. Steigman        93
            Additional Forms Created
• Immediate Needs Assessment (ACT)

• Comprehensive Psychiatric Rehabilitation
  Assessment

• Residential Intake and Functional Assessment
  forms (child and adult versions)
3/02/2010           Presented by J. Steigman     94
         Questions and Answers for the
            Assessment Sub-Group




3/2/10              Presented by J. Steigman   95
Individual Action Plans
         (IAP)

3/02/10   Presented by A. Arnold   96
          Individualized Action Plan (IAP)
• The IAP, formerly known as the treatment
  plan/service plan is used to document goals,
  objectives, and therapeutic interventions.

• To promote principles of recovery, the
  “Individualized Action Plan” (IAP) reflects the
  recovery concept of shared decision making.


3/02/10                Presented by A. Arnold       97
          Individualized Action Plan (IAP)
• Provides a standardized method that assures that
  the IAP process is conducted in a manner that meets
  all medical necessity requirements and complies
  with all regulatory standards.
• Designed to incorporate evidence based practices
  and promotes person centered planning.
• Links to needs identified during the assessment
  phase and during treatment.

3/02/10               Presented by A. Arnold        98
     Individualized Action Plan (IAP)
• The IAP serves as a tool to collaboratively build goals
  and objectives, which reflects both medical necessity
  and the desired outcomes of the person served in his
  or her own words.

• The design promotes a recovery, strengths based
  approach that facilitates the achievement of a
  person’s life goals.

• The design encourages collaboration among service
  providers and natural supports.
3/02/10                Presented by A. Arnold           99
          Individualized Action Plan (IAP)
• The design incorporates transition/discharge
  planning from the earliest point in the service
  delivery process.

• The transition/discharge section emphasizes the
  criteria for discharge and identifies the supports and
  services necessary upon discharge from the
  program.

3/02/10                Presented by A. Arnold          100
           IAP Review/Revision
• Designed to document information of ongoing
  review (s), revision (s) of goals and objectives.

• Minimizes duplication and maximizes the
  documentation of information, which demonstrates
  evidence and/or rationale for revision.


3/02/10                 Presented by A. Arnold        101
                IAP Review/Revision
 Use the IAP Review/Revision form in the following
  ways:
          • Reviews - to record the progress of the individual served.
            This will facilitate the identification and tracking of
            treatment goals/objectives and progress made.

          • Revisions – to add a new goal; change goals, objectives or
            interventions; or change the frequency or duration of
            services.


3/02/10                        Presented by A. Arnold                    102
            IAP Review/Revision
• Use both pages of the IAP Review/Revision form for
  either a Review or Revision.

• Additional goal and/or objective sheets should be
  added as necessary.



 3/02/10               Presented by A. Arnold          103
           IAP Review/Revision
• If a goal/objective is new and not currently
  supported by the most recent Comprehensive
  Assessment, it is required to also complete a
  Comprehensive Assessment Update form.

• For OMH residential programs, the Residential
  Functional Assessment needs to be updated.

3/02/10               Presented by A. Arnold      104
          Psychopharmacology Plan
• Used for individuals receiving outpatient
  psychopharmacology services only.

• Serves as a tool to collaboratively build goals and objectives,
  which reflects both medical necessity and the desired
  outcomes of the person served in his or her own words.

• Is recovery focused and based on an individual’s strengths
  and abilities and the achievement of his/her life goals.
3/02/10                    Presented by A. Arnold                   105
          Psychopharmacology Plan
• Designed to encourage collaboration among service
  providers and natural supports.

• Designed to incorporate evidence based practices
  and promote person centered planning.




3/02/10              Presented by A. Arnold          106
          Relapse Prevention Plan
• Relapse Prevention Plan is designed to be a part of
  the IAP for individuals in PROS and ACT programs.

• This document is to be completed by the individual,
  his/her supports (that they choose to include) and
  staff.



3/02/10               Presented by A. Arnold        107
          Relapse Prevention Plan
• It helps the individual figure out ways to stay well and prevent
  a relapse of symptoms and to continue moving toward their
  life goals.

• The plan helps the individual identify things, places, people,
  medications, etc., that might trigger a relapse and what
  he/she can do or need from others to help prevent a relapse.

• The plan helps the individual identify resources and supports
  to take care of his/her personal affairs in the event he/she is
  not able to.
3/02/10                    Presented by A. Arnold               108
          Discharge Plan Instructions
• Completed in collaboration with the individual and provided
  to him/her at the time of discharge. The development of this
  plan should be initiated as early in the treatment as possible
  to ensure steps are taken to provide continuity of care.

• For OASAS programs only, when completing the Discharge
  Plan Instruction, a substance abuse relapse prevention plan
  description needs to be included.

• The Plan includes referral plans and aftercare
  recommendations.

3/02/10                   Presented by A. Arnold                109
          Discharge Summary
• Summarize reasons for discharge, summary of
  services, and outcomes on goals.




3/02/10           Presented by A. Arnold    110
      Questions and Answers for the
             IAP Sub-Group




3/02/10          Presented by A. Arnold   111
          Progress Notes

3/02/10        Presented by June Newill   112
          Progress Notes Standard
               Components
• Documentation links to specific goals in IAP
• Billing Strip Instructions




3/02/10            Presented by June Newill      113
           Pre Admission
• Used for documenting services,
  interventions and methods provided
  prior to admission.
     Screening/Admission Note
• Designed to document reason for admission.
• Summarizes services/interventions to be
  provided initially.
              Shift/Daily
• Used for documenting activities,
  interventions, methods and individuals’
  responses.




3/02/2010        Presented by June Newill   116
         Group Progress Note
• Designed to document participation and
  response of persons in group activities.
          Contact Progress Note
• Used to document interventions,
  services and methods.




3/02/10          Presented by June Newill   118
          Coordination of Care
• Used for billable or non-billable case
  consultation, family consultation or collateral
  contact services.
• Contact can be face to face or by telephone.
• Identifies action steps and responsible parties.


3/02/10             Presented by June Newill    119
          Summary Progress Note
• Used for services requiring weekly, bi-weekly, monthly or
  another specified date range documentation.
• Summarizes progress made by the individual toward the IAP
  goals and significant changes in the person’s environment
  over the course of the time period.




3/02/10                 Presented by June Newill              120
Partial Hospitalization Progress Note

• Designed for documenting participation
  in all individual and group activities.
• Can document three activities per note,
  adding more pages when needed.
          Nursing (Long or Short)
• Used to document therapeutic interventions
  and person’s response to the intervention(s)
  during a specific contact.
• To be completed by a LPN, RN, BSN, or MSN.
• Use either long or short version depending on
  type of documentation/services needed.
• Can be used as a shift note by a nurse in any
  program.
3/02/10            Presented by June Newill   122
 Individual Counseling Psychotherapy
             Progress Note
• Used to document therapeutic interventions
  and person’s response to the interventions
  during a specific contact.




3/02/10           Presented by June Newill     123
              Psychopharmacology/
              Psychotherapy Notes
•         Designed to document activities relating to
          psychopharmacology and psychotherapy.
•         Used by Psychiatrists and/or Advanced
          Practiced Registered Nurses/Clinical Nurse
          Specialists when that individual is the
          provider of both medication management
          and psychotherapy services.
3/02/10                  Presented by June Newill       124
             Psychopharmacology/
          Psychotherapy for ACT Teams
• This note is designed for use by ACT Teams to
  meet ACT Team requirements.




3/02/10            Presented by June Newill
                                              125
              When a New Issue is Presented
•         There are three options available for staff using this section of the
          progress note (new Issues refers to all new issues/stressors/extraordinary
          events).
1.        If no new issues are presented, mark “None Reported” and proceed to the
          next section.
2.        If person reports a new issue that was resolved during the contact, check
          the “New issue resolved, no update required” box. Briefly document the
          new issue, identify the interventions and indicate the resolution.
3.        If person presents a new issue that was not resolved and represents a need
          that is not already being addressed in the IAP, check the box indicating a
          “CA/IAP Plan Update Required” and record notation that new issue has
          been recorded on a Comprehensive Assessment.


     3/2/10                          Presented by June Newill                   126
         Questions and Answers for the
           Progress Note Sub-Group




3/2/10              Presented by June Newill   127
           Web Interface

3/2/2010      Presented: Scott Lloyd, VP of MTM Services   128
3/2/2010   Presented: Scott Lloyd, VP of MTM Services   129
3/2/2010   Presented: Scott Lloyd, VP of MTM Services   130
    Evaluation Protocol

3/02/10    Presented by June Newill   131
           Evaluation Levels and Tools
• Program Level Evaluations
      – To be completed after local pilot trainings
      – Assessment of Local Program Pilot Training and
        “Kickoff”
           • Evaluate quality of today’s training and supports
             received
           • Evaluate success of agency training
      – One evaluation per program participating in the
        pilot
                         Presented by Scott Lloyd, VP of MTM and
3/2/2010                                                           132
                              Sherri Kaplan, Evaluation Lead
           Evaluation Levels and Tools
• Tools you will use:
      – NYSCRI Local Program Pilot
        Implementation Survey (Attachment A)
      – NYSCRI Pilot Study Program Type List
        (Attachment B)



                   Presented by Scott Lloyd, VP of MTM and
3/2/2010                                                     133
                        Sherri Kaplan, Evaluation Lead
           Presented by Scott Lloyd, VP of MTM and
3/2/2010                                             134
                Sherri Kaplan, Evaluation Lead
           Presented by Scott Lloyd, VP of MTM and
3/2/2010                                             135
                Sherri Kaplan, Evaluation Lead
           Evaluations and Tools
• Direct Staff Form “Mark-up” Process
     – To be completed during pilot study
     – Evaluation of pilot forms
     – Notations made directly on blank forms by
       participating program staff
     – Each participating staff member required to mark
       up one form for each mandatory type piloted
• Direct staff members’ chance to influence the
  final product
• Comment on form layout, data elements, spacing
  issues, etc.
                     Presented by Scott Lloyd, VP of MTM and
3/2/2010                                                       136
                          Sherri Kaplan, Evaluation Lead
           Evaluations and Tools
• Tools you will use:
      – Set of blank pilot forms
      – NYSCRI Pilot Form Markup Instructions
        and Cover Sheet
      – Form Markup Staff Cue Sheet
        (Attachment C)
      – Form Markup Instruction Sheet
        (Attachment D)
                  Presented by Scott Lloyd, VP of MTM and
3/2/2010                                                    137
                       Sherri Kaplan, Evaluation Lead
           Presented by Scott Lloyd, VP of MTM and
3/2/2010                                             138
                Sherri Kaplan, Evaluation Lead
           Presented by Scott Lloyd, VP of MTM and
3/2/2010                                             139
                Sherri Kaplan, Evaluation Lead
           Evaluation and Tools
• Program Level Pilot Evaluation
   – To be completed during last week of pilot
   – Evaluation of overall pilot (Attachment E)

• Tools you will use:
   – Program Level Pilot Evaluation Summary



                Presented by Scott Lloyd, VP of MTM and
3/2/2010                                                  140
                     Sherri Kaplan, Evaluation Lead
           Presented by Scott Lloyd, VP of MTM and
3/2/2010                                             141
                Sherri Kaplan, Evaluation Lead
           Presented by Scott Lloyd, VP of MTM and
3/2/2010                                             142
                Sherri Kaplan, Evaluation Lead
           Program Evaluation Focus Areas
1. Identification of how many times each pilot
   form/process was used by direct care staff during the
   pilot study.
2. Evaluate to what extent does each pilot form used
   collect the data elements direct care staff need to do
   their job well
3. Evaluate to what extent does each pilot form used
   contain unnecessary data elements
4. Evaluate to what extent does each pilot form support
   compliance with regulations and payer requirements
   (DMH, MBHP, Medicare, MCOs, CMS, etc)
                    Presented by Scott Lloyd, VP of MTM and
3/2/2010                                                      143
                         Sherri Kaplan, Evaluation Lead
           Program Evaluation Focus Areas
5.    Evaluate to what extent does each pilot form used support
      compliance with accrediting body standards (CARF, JCAHO,
      COA, NCQA, etc)
6.    Evaluate to what extent does each pilot form used support
      a ‘Person Centered, Recovery Oriented” approach to
      services
7.    Evaluate the overall clinical flow/ clinical content of the
      NYSCRI forms/documentation processes
8.    Compare each new pilot form used with the equivalent
      form being used just prior to the pilot in terms of support
      for quality clinical/ recovery focused services
9.    Evaluate to what extent did the pilot forms used
      unnecessarily collect information more than once
                       Presented by Scott Lloyd, VP of MTM and
3/2/2010                                                         144
                            Sherri Kaplan, Evaluation Lead
           Pilot Evaluation Timeline
                   Key Dates
• March 3-12: Local program training and pilot
  “kickoff”
• March 15-April 23: Pilot study period
• March 3-12: Completion of NYSCRI Local
  Program Implementation Survey
• April 5-April 20: Forms mark-up
• April 20-23: Completion of Program Level
  Evaluation Tool
• April 27: Pilot study exit interview
                 Presented by Scott Lloyd, VP of MTM and
3/2/2010                                                   145
                      Sherri Kaplan, Evaluation Lead
            Concurrent
          Documentation

3/02/10                   146
 Concurrent Documentation Setup
• Group & Individual Sessions
   – Assessments, Treatment Plans – Real Time
   – Progress Notes - Last 10 min. Groups & Individual
• Scripts – Know how you are going to explain the process to
  your clients before your session.
• Technology Needed - What technology is needed/available?
• Office Setup – Do you need to move computers, screens,
  office furniture?
• HIPAA Compliance - Carrying information into the field offers
  specific risks.
• Clinical Judgment - Concurrent documentation will not work
  with every client in every situation.
3/02/10              Presented By: Scott C. Lloyd, VP of MTM   147
 Concurrent Documentation Setup
• Treatment Planning/Individual Session Sample
  Script –
After introductions:
  “We will have open communication during our
  session today, which means that I will be taking
  notes along the way, and we will review the
  information at the end of the service today. This will
  ensure that we are providing you with the
  appropriate services to address your needs.”

3/02/10            Presented By: Scott C. Lloyd, VP of MTM   148
 Concurrent Documentation Setup
• Sample Script – After introductions on both sides:
  “We are going to utilize a new note taking strategy
  during our session today. Instead of taking notes
  after the session, we will take notes during the
  session which will allow us to better focus on and
  help us to be in agreement on what is being
  expressed. In doing so I will allow you to read the
  notes I take to actively participate in the reflection
  process.”


3/02/10             Presented By: Scott C. Lloyd, VP of MTM   149
Concurrent Documentation Process
• Perfect complement to the use of the Uniform
  Case Record.
Some of the Benefits:
• Quality of Life for Staff. Results in less anxiety and
  stress for direct service staff which leads to
  enhanced morale greater job satisfaction, and sense
  of well-being.
• Eliminates the staff’s “treadmill” of always having to
  catch up on documentation of services, that is, to
  keep paperwork timely and accurate.
3/02/2010             Presented by J. Steigman         150
Concurrent Documentation Process
• Increased focus of direct care work- planned
  service delivery focus based on treatment
  plan formulation. Less meandering.

• Cutting out-of-session documentation time
  results in greater ability to conduct other
  activities (phone calls, etc) and allows for
  greater capacity/productivity.
3/02/2010          Presented by J. Steigman      151
Concurrent Documentation Process
• Supports recovery focused services (Client
  participation, client benefit).
• Because clinicians will clarify their impressions and
  therapeutic interventions by putting them into
  words in front of the consumer/family, this enhances
  the therapeutic value of the session and increases
  engagement.
• Ensures greater content accuracy b/c of reduced
  time between the actual service and writing the
  progress note.
• Compliance with submission and billing
  requirements.
3/02/2010             Presented by J. Steigman       152
     Pederson-Krag Center’s Concurrent
    Documentation Pilot-9/16/09-10-27-09




3/02/2010         Presented by J. Steigman   153
     Pederson-Krag Center’s Concurrent
    Documentation Pilot-9/16/09-10-27-09




3/02/2010         Presented by J. Steigman   154
     Pederson-Krag Center’s Concurrent
    Documentation Pilot-9/16/09-10-27-09




3/02/2010         Presented by J. Steigman   155
                         Training Tips
1.     Do not treat the Comprehensive Assessment as a sequenced
       interview that has to follow the instrument line by line. It is to
       serve as a document of findings resulting from an interview.
       Clinicians are free to approach the gathering of information in a
       manner that is a "good fit" for the client/family and the clinician.
2.     The Comprehensive Assessment has two versions, one for
       adults and one for children/adolescents.
3.     All elements are required to have a notation even if it is to
       document "None Reported" or "Not Clinically Appropriate". This
       will give the impression to reviewers that the element has not
       been ignored.
4.     Try to capture as much information on the form prior to the
       arrival of the person served. This will permit more face-to-face
       interaction between the person served and the clinician and
       possibly contribute to an enhanced relationship and session.
3/2/2010                       Presented by J. Steigman                  156
                      Training Tips
5.   Please try not to get frustrated and remember that these
     NYSCRI documents are a work in process. Your input is vital.

6.   We have provided both a paper form and electronic WORD
     form for each of the NYCRI form types. Each program can
     chose which format they prefer to use during the pilot study
     based on computer availability. The "after pilot" templates
     will permit the agencies to add their agency name to the
     documents.




3/02/2010                  Presented by J. Steigman                 157
                      Training Tips
7.   Other forms already in existence with agencies documenting
     client rights, mental status exams, lethality assessments and
     registration are not part of the NYSCRI initiative. A sample
     Personal Information Sheet, Risk Assessment and Mental
     Status Assessment are being provided as samples for your
     review and possible use, if your agency does not have locally
     produced versions of these forms.
8.   It is useful to train in small groups and to offer multiple
     training sessions.
9.   It is helpful to train using a “filled-out” set of forms.
     Therefore, it may be helpful to pick a person being served
     from your facility that your staff is familiar with. This also
     helps explain how the outcomes and recovery process are
     reflected in the new forms.
3/02/2010                   Presented by J. Steigman              158
Thank You for your Time!
    Any Questions?


3/02/2010   Presented by J. Steigman   159

								
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