60 day review Template by xor56373

VIEWS: 43 PAGES: 8

									                                           City of Philadelphia
                        Department of Behavioral Health/ Mental Retardation Services
                                     Community Behavioral Health

                             Family Based Clinical 60 Day Review Form
                      *Please attach the most recent Family Based Treatment Plan*


Date:                Agency:                           Person completing form/title:

Child/Adolescent’s Last Name:                                First Name                       DOB:

Family Based Authorization Period:                to

   I. Demographic Information

          A. Has the /child/adolescent/family moved within the last 60 days?
          _______Yes _________ No

          (1.) If yes, please provide detailed information as to why child/adolescent/family has
          moved and where (include mailing address and telephone number).




          B. Are there any changes in the household composition within the last 60 days? (i.e.
          paramour moved in, incarceration of a family member, child moved out of the home or
          was placed etc.) ____________Yes _____________No


          (1.) If yes, please provide detailed information regarding the changes to the household
          composition.




          C. If changes, how have the changes affected child/adolescent/family? (Please be specific)




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          D. If any changes, how is the Treatment Plan addressing the changes? (Please be specific)




  II. DSM Diagnosis

          A. Has the child/adolescent’s mental health diagnosis changed in any of the five Axes
          within the last 60 days? ___________Yes _____________ No

          (1.) If yes, please provide code and write out diagnosis include all five Axes.
          (based on most recent evaluation)

          Axis I
                     _____________________________________________________________________________

          Axis II
                     _____________________________________________________________________________

          Axis III
                     ____________________________________________________________________________

          Axis IV
                     _____________________________________________________________________________

          Axis V
                     _____________________________________________________________________________



  III. Service Up-date

          A. Has the child/adolescent received any additional services within the last 60 days?
          _________Yes __________ No


          (1.) If yes, please list all new services that the child/adolescent is receiving.

Service                         Provider of service     Date started   How often        Actively participating
                                Name and phone                         provided         In treatment?
                                number

                                                                                        ____ Yes ____ No


                                                                                        ____ Yes ____ No




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IV. Medication History

   A. Is the child/adolescent prescribed any medication? _______Yes _______No

   B. Have there been any changes in child/adolescent’s prescribed medication within the
   last 60 days? ________Yes __________ No

   If you answered yes to either of the last two questions, please complete the following
   questions.


   (1.) What medication(s) is the child/adolescent prescribed? (list all medication including
   dosage/frequency)




   (2.) Who is the prescribing physician? (include name address & telephone number).




   (3.) Is the child/adolescent compliant with taking his/her medication?
    _______Yes ______ No

   (a.) If no, what is the barrier(s) to medication compliance? (Please be specific)




   (b.) What intervention(s) is the Family Based Treatment team utilizing to eliminate the
   barrier(s)? (Please be specific)




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V. Behavioral Concerns

 A. What strengths does the child/adolescent possess?




 B. What are the child/adolescent’s behavioral concerns? (i.e. D&A, Trauma, etc.)




 C. What behavioral issues do the child/adolescents family members’ have? (Identify the
 family member and their specific concern i.e. D&A, MH, Domestic Violence, parenting skills etc.)




 D. What treatment interventions are being utilized?




 D. What is the impact of the interventions being utilized and is the client responding?

 (1.) Positive- (specify what is positive about the intervention)




 (2.) Negative- (specify what is negative about intervention)




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VI. Family Involvement

    A. Are the parents/caregivers involved in treatment? ___________Yes ________ No

    (1.) If yes, in what capacity are the parents/caregivers involved in treatment?




    (2.) If no, what barrier(s) is preventing the parents/caregivers from being involved in
    treatment?




VII. Family Based Contingency Funds

    A. Has the treatment team utilized any of the Family Based contingency funds to assist
    the child/adolescent/family? ________Yes ________ No

    (1.) If yes, explain the reason, the amount spent and what the funds purchased.




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  VIII. Discharge Preparation

         A. What are the discharge criteria?




         B. Does the Family Based Treatment team assess that the discharge criteria will be
         achieved within the approved authorization period? _________Yes ________No

         (1.) If no, please explain why not.




         C. What is the aftercare plan?




         (1.) What referrals and/or linkages have been made to connect child/adolescent/family to
         community based supports and resources?


Person Referral/Linkage   Referral/Linkage     Address/ phone   Date               Anticipated Start Date:
Made for:                 Made To:             number           Referral/Linkage
                                                                Made:




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                    Explanation/Instructions for Completing the
                    Family Based Clinical 60-Day Review Form

The Family Based Clinical 60-Day Reviews will take the place of the Family Based
Concurrent Reviews. The purpose of the 60-day review’s are to assist the Department of
Behavioral Health/ Mental Retardation Services (DBH/MRS) and Community Behavioral
Health (CBH) to more efficiently collect state required data and better support Family Based
providers in servicing children/adolescences and their families through more frequent review
and monitoring. The Family Based Clinical 60-Day Review form is divided into eight
sections. Each section addresses Pennsylvania State policy requirements for the provision of
Family Based Services as represented in the Bold.

Section I. Demographic Information
The Family Based TX team is required to provide CBH with up-dated information on any
changes to the household composition that may have occurred within the last 60 days and the
impact of any changes on the child/adolescent/family.
The goal of Family Based Services is to help prevent an out-of-home placement or
psychiatric hospitalization of children/adolescences with mental health and emotional
disturbance. By providing, whatever services are necessary to enable families to
maintain their role as the primary caregivers for their children.

Section II. DCM Diagnosis
The Family Based TX team is required to provide CBH with up-dated information regarding
any changes to the child/adolescent’s mental health diagnosis that may have occurred within
the last 60 days.
A physician or licensed psychologist must recommend Family Based Services as a
medical necessary.

Section III. Services Up-date
The Family Based TX team is required to provide CBH with an up-date regarding any
additional services the child/adolescent received within the last 60 days i.e., in-school
TSS/BSC, partial school day program, emergency MH service (CRC), psych./psych.
evaluation/testing etc.
Family Based Behavioral Health Service is a comprehensive mental health service,
which provides treatment, case management, and family support services. When FB
services are authorized, there are limits to other mental health services that may be
billed to the child/adolescent. If there is more than one child care system involved
during the period that FB is involved the FB TX must develop a jointly written TX plan
which documents service responsibilities of each system.

Section IV. Medication History
The Family Based TX team is required to provide CBH with information regarding any
changes within the last 60-days to child/adolescent’s medication status (if the
child/adolescent is prescribed medication).
If there is more than one child care system involved during the period that FB is
involved the FB TX must develop a jointly written TX plan which documents service
responsibilities of each system.




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Section V. Behavioral Concerns
The Family Based TX team is required to provide a report of the child/adolescent’s strengths
and behavioral concerns to CBH. The FB TX team is responsible to elaborate on the
therapeutic interventions that the FB TX team is utilizing to address the behaviors. Further,
the FB TX team must report on the child/adolescent’s response to the interventions, the
positive/negative/indifferent aspects of the interventions, the clinical progress and barriers
preventing progress.
Family Based Behavioral Health Services are primarily treatment services which may
employ individual, family and group therapy and counseling, sensitivity training, play
therapy, recreational therapy, cognitive techniques, parenting skills, assertiveness
training, reality therapy, rational/emotive therapy, modeling, behavior modification,
coping skills and other treatment approaches.

Section VI. Family Involvement
The Family Based TX team is required to provide CBH with the status of parent/caregiver
involvement in TX.
Family Based Services are provided to the child/adolescent and members of the family
who have agreed to participate in the service. It must be documented that at least one
adult member of the family has agreed to participate in the service.

Section VII. Family Based Contingency Funds
The Family Based TX team is required to provide CBH with an up-dated account of all
Family Based Contingency money spent to assist the child/adolescent/family within the last
60 days.
Support to help elevate stressors to ensure that families are able to maintain their role
as the primary caregivers for their children.

Section VIII. Discharge Preparation
The Family Based TX team is required to provide CBH with a report regarding discharge
planning every 60 days. The FB TX team and the child/adolescent/family should be mindful
of and planning for discharge from the start of the service. The FB TX team is required to
identify realistic discharge criteria’s and assessed their achievability within the 32-week
authorization period. The FB service involves assessment, planning, service linkage, referral,
and family-support. TX team is responsible to identify an effective aftercare plan for the
child/adolescent/family and should be assessing and making any necessary referrals for
aftercare services immediately depending on the anticipated wait for the services to be
implemented i.e. Big Brother/Big Sister, OP therapy, TCM Services, recreational services etc.
It is a state requirement that the Family Based TX team provide transition to agencies
and practitioners in the community who will provide services and support for the
child/adolescent/family after Family Based Behavioral Health Services are ended.




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