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Comprehensive Service Planning A New Employee Orientation (NEO) Required Training

Comprehensive Service Planning A New Employee Orientation (NEO) Required Training. Module Objectives. Understand the overall service planning process Understand the various content components of a service plan

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Comprehensive Service Planning A New Employee Orientation (NEO) Required Training

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  1. Comprehensive Service PlanningA New Employee Orientation (NEO) Required Training Self-study Module June 2012

  2. Module Objectives • Understand the overall service planning process • Understand the various content components of a service plan • Learn how to create and record a comprehensive and effective service plan • Understand service plan timeframes and signature requirements Okay, let’s get started!…

  3. Assessments: the foundation for service planning • To determine medical and behavioral health needs • To gather background information • To find out the member’s/family’s strengths • To find out where the member is and determine their goals • To consider possible services and interventions What is the purpose of an assessment?

  4. Assessments: the foundation for service planning • strengths and natural supports • clinical and professional supports During the assessment process we begin to consider interventions and treatment goals for the member’s Service Plan. These interventions usually fall into two broad categories: These two concepts are examined on the next slides…

  5. What are examples of naturalsupports? Social connections, organizations, services and affiliations available in the community can serve as a social network, safety net and resource for activities, education, support and leisure. Friends, family, neighbors, acquaintances, co-workers, pets, hobbies, exercise, faith/religious communities. Assessments: the foundation for service planning

  6. Assessments: the foundation for service planning What are examples of clinical supports? • Resources available to help member meet identified recovery goals • These include: ongoing Adult Recovery Teams/Child and Family Teams, Assessment Tools, the Demographic Data form, and Service Plans. • Treatment/professional/alternative services provided to member The goal of treatment is to move members from reliance on clinical supports to more reliance on natural supports…

  7. Service PlanningOverview: A model ADHS/DBHS supports a model for assessment, service planningand service delivery that is strength-based, person-centered, family friendly, culturally sensitive and clinically sound and supervised. The model is based on four equally important components…

  8. Service PlanningOverview: A model • Input from the member and family/significant others regarding their individual needs, strengths and preferences; • Input from other individuals who have integral relationships with the member/family; • Development of a therapeutic alliance between the member and behavioral health provider that fosters an ongoing partnership built on mutual respect and equality; • Clinical expertise. Service planning and service delivery modelcomponents:

  9. Service PlanningOverview: 7Principles Service Plans… 1) are developed with an unconditional commitment to persons enrolled in the behavioral health system and their families; 2) begin with empathetic relationships that foster ongoing partnerships built through respect and equality throughout the service delivery system; 3) build on a positive therapeutic alliance between the behavioral health provider and service recipient so that the service recipient feels comfortable with the provider and feels a sense of safety and trust in the treatment process;

  10. Service PlanningOverview: 7Principles(continued…) Service Plans… 4) are developed collaboratively with members/families to engage and empower their unique strengths and resources; 5) include other individuals important to the person; 6) are individualized, strength-based, culturally appropriate and clinically sound; and, 7) are developed with the expectation that the person is capable of positive change, growth and leading a life of value. The member’s culture helps shape the service plan…

  11. Service PlanningOverview: Culture The full array of identified services are to be used to support the member’s strengths and cultural preferences. Cultural factors must be incorporated into the Service Plan and can be incorporated into the strengths, identified needs, objectives, goals, or interventions sections on the Service Plan. Examples of member/family culture: values and beliefs, traditions, language, family history and hierarchy, gender orientation, sexual preference, age, social status, roles and relationships, hobbies, lifestyle, holidays, faith. A combination of traditional and non-traditional services has proven the most effective approach in achieving long term benefit from treatment.

  12. Service PlanningOverview: Culture If the member has an identified primary language other than English, this should be indicated on the Service Plan. This language preference is often overlooked by service planners! If the member would benefit from utilizing an interpreter, you must offer this Covered Service, and if interpretive services are to be used, this must be listed on the Service Plan. If interpretation services were offered and declined by the member, make sure this is noted on the Service Plan progress note. Who is involved in the service planning process?…

  13. Service PlanningOverview: The team The state model incorporates the concept of a ‘team’, established for each person receiving behavioral health services. For children, this team is the Child and Family Team (CFT) and for adults, this is the Adult Recovery Team (ART). Themembermust be included in the ‘team’ development of the service plan. Team members may also include family members, parents/guardian, designated representatives, agency representatives and other involved parties. Any team members may participate in service planning through the ART/CFT process. Service planning is a team effort!

  14. Service PlanningOverview: The team Regarding service planning, the functions of the CFT and ARTinclude: • Continuous evaluation of the effectiveness of treatment through the CFT and ART process, the ongoing assessment of the person, and input from the person and his/her team resulting in modification to the service plan, if necessary; • Provision of all covered services as identified on the service plan, including assistance in accessing community resources as appropriate; and, • Development/implementation of transition plans prior to discontinuation or modification of behavioral health services.

  15. Service PlanningOverview: Coordinating care Behavioral health providers must coordinate with the person’s health plan, PCP or others involved in the care or treatment of the individual, as applicable, regarding service planning recommendations and the delivery of services (see Section 4.3, Coordination of Care with AHCCCS Health Plans, Primary Care Providers and Medicare Providers). • Covered Services should be in conjunction with community and natural supports. • Interventions should identify all services to be provided by agency and subcontractors. • ARTs and CFTs should include all persons involved in the care of the member. • Service Plans developed at a CFT/ART should be distributed to all agencies providing services to the member. (Regardless of whether or not they attend the CFT/ART).

  16. Service PlanningOverview: Writing the plan Behavioral health assessments and Service Plans must be completed by credentialed behavioral health professionals (BHPs) or behavioral health technicians (BHTs) who are trained on the minimum elements of the assessment and Service Plan contained in the policy. In the event that a BHT completes the service plan, a BHP must review and sign the Service Plan. Behavioral health provider staff who conduct assessments and develop Service Plans must also receive clinical supervision. Who completes the Service Plan?

  17. Service PlanningOverview: The completed plan The behavioral health recipient must be provided with a copy of his/her plan. If a member has a question regarding his or her Service Plan that has not been sufficiently addressed by the provider, the member may contact CPSA Member Services at (520) 318-6946 or 1-800-771-9889 (1-866-318-6960 for TTY). (More discussion about members having issues with their Service Plan comes later in this module) Next we will examine Plan specifics…

  18. Service PlanningThe Service Plan All individuals being served in the public behavioral health system must have a written plan for services upon an initial request for services and periodic updates to the plan to meet the changing behavioral health needs for individuals who continue to receive behavioral health services. ADHS/DBHS does not mandate a specific service planning tool or format. Service Plans must be utilized to document services and supports that will be provided to the individual, based on behavioral health service needs identified through the person’s behavioral health assessment. • If a person is in immediate or urgent need of behavioral health services (see Section 3.2, Appointment Standards and Timeliness of Service), an Interim Service Plan may need to be developed to document services until a complete service plan is developed. A complete Service Plan, however, must be completed no later than 90 days after the initial assessment appointment.

  19. Service PlanningThe Service Plan Writing an effective service plan: • Goals are global in nature. Break down each goal into reasonable steps or objectives. • Objectives must be measurable and attainable. • Strengths are assessed and utilized. Needs are prioritized. • Interventions should list all services that your agency or outside agencies are providing, or will provide, as well natural supports.

  20. Service PlanningThe Service Plan Service Plans contain: • The member/family vision that reflects the needs and goals of the person/family; • Identification of the member’s/family’s strengths; • Measurable objectives and timeframes to address the identified needs of the member/family; • Identification of the specific services to be provided and the frequency with which the services will be provided; • The signature of the member/guardian and the date it was signed; • Documentation of whether or not the member/guardian is in agreement with the plan;

  21. Service PlanningThe Service Plan Service Plans contain: • The signature of a clinical team member and the date it was signed (more on signatures in a later slide) • The signature of the person providing Special Assistance, for persons determined to have Serious Mental Illness who are receiving Special Assistance; and, • The Service Plan Rights Acknowledgement (see Provider Manual Attachment 3.9.1: Service Plan Rights Acknowledgement Template, dated and signed by the member or guardian, the person who filled out the Service Plan, and a behavioral health professional if a behavioral health technician fills out the Service Plan.

  22. Service PlanningThe Service Plan Service Plans: Remember, a Service Plan must be completed within 90 days of the initial assessment, though it is usually completed much sooner.An Interim Service Plan may also be utilized to bridge the gap between the initial assessment and the completion of the first Service Plan. The Interim Plan is developed by the assessor and the member. Next up is a look at the Service Plan document…

  23. Service PlanningThe Service Plan The following slides will take you through the main components of aService Plan, examining each component in terms of the information included, and tips for effective completion.The Plan sections (circled in red) will be shown as they appear on a service plan form, followed by discussion slides for each section.

  24. The Service Plan:Recovery Goals/Vision This section should describe what success looks like for the member/family and how they will know when current services are no longer needed. The client should provide this goal and if there is family involvement, the family’s vision can also be included. These are often long term outcome(s) a member or family wants as a result of receiving behavioral health services. When applicable, this can be written as a quote in the member’s own words. Examples: -“I want my family to get along better and fight less.”- “I want to become sober and get a full time job.” - Member wants to be able to better manage her child’s behavior and to improve her child’s behavior in school.

  25. The Service Plan:Person’sStrengths Summarize the strengths of the member/family. These are traits, abilities, resources, characteristics, etc., that are relevant for and/or will assist the member with their needs and objectives on this Plan. These can either be strengths that the client has identified, or strengths identified by members of their CFT or ART. These strengths will be used in the development of treatment interventions in the Service Plan. This section will be modified as more strengths are identified in the future. Natural and community supports can be considered as strengths on the Service Plan.

  26. The Service Plan:Identified Needs/Specific Objectives Needs:Are NOT an intervention or covered service, but rather, what the intervention or service will help the member change or achieve.Example: If the intervention is therapy, the Need should be what the therapy will help the member change or accomplish; such as better communication with family, or decreased anxiety. The Need is also what is measured on the plan, NOT the interventions.Objectives:Specific action step(s) the member or family will take toward meeting each Identified Need. Objectives are the things they are going to do. Let’s give you some examples…

  27. The Service Plan:Identified Needs/Specific Objectives Examples:Need: “I need to have more talks with my son without yelling.” Objective: “Walk away from my son when I feel angry before I start yelling.”Need: “I want to drink less each night at home.” Objective: “Call my friend Joseph when I have the urge to drink.”Need: “Income to support my family.” Objectives: 1. Get a job (1 month) 2. Apply for food stamps (1 week) 3. Seek rental assistance (1 week)

  28. The Service Plan:Identified Needs/Specific Objectives Final Example:“Mary needs family therapy” is not an Objective. An appropriate Objectivecould be: Mary would like to fight less with her sister. An even better example, reflecting person-centered care, would be a direct quote from Mary, “I would like to fight less with my sister.” Therapy is an Intervention, and will be written in the ‘Interventions’ section of the Service Plan. What will therapy help Mary change or accomplish? That is the Need.

  29. The Service Plan:Identified Needs/Specific Objectives An acronym to remind you what makes for a good Objective:M A T R SMeasurable, Achievable, Timed, Realistic, Specific • Objectives should be brief, clear statements that meet the MATRS test. • They should make sense to the member/family who “owns” the Service Plan. • It is recommended that the Service Plan contain no more than five or six objectives at one time.

  30. The Service Plan:Measures • The ‘measures’ on the Service Plan provide quantifiable information that measures/reflects member progress toward an identified Plan Objective. • For example, if a member Objective is to argue less with their spouse, how will we know when that Objective is achieved? The ‘measures’ information helps to define this: • Member currently argues with spouse an average of once a day. The desire is to reduce this to two times a week or less. • Remember, it is the member who is crucial in identifying current and desired levels they want to achieve for each Objective. You can help members to keep their Objectives realistic and attainable… remember MATRS!

  31. The Service Plan:Measures Examples of measures for member A and member B:Current Measure: current baseline for the Objective… A) John currently reports arguing with spouse every day.B) Suzy currently drinks 3 glasses of wine per night.Desired measure:where the member would like to be…A) Reduce arguments to two per week or less.B) Suzy will drink no more than one glass of wine per day. These Measures should be linked to the Behavioral Health Objective of the member, not to the Interventions! The frequency of interventions is written in the “Interventions” section of the plan.

  32. The Service Plan:Measures Achieved Measure:This is the new or achieved measure. Determined/recorded when the plan is reviewed at the Target Date…A)John now fights with spouse 1-2 times per weekB) Suzy now drinks 2-3 glasses of wine per night.Measure Met:Answers the question, “Was the desired measure met?” Determine/recorded at the same time as the Achieved Measure information…A)Yes (desired measure was 2x /week or less)B) No (desired measure was no more than one glass of wine/day)

  33. The Service Plan:Interventions Interventions to Meet Objectives:Interventions should describe how each of the Service Objectives is going to be met. While this should include covered behavioral health services including type and frequency, it is also important to identify those other natural supports or community services that might be drawn upon to help meet the service plan objective, (i.e., AA group, volunteering at the Humane Society, meetings with a child’s teacher, meditation/exercise). Additionally, it is important to identify the strengths and motivation the member has to achieve the objectives, including outside supports that have been identified in the assessment.

  34. The Service Plan:Interventions Interventions to Meet Objectives - Examples: Specific Service - Attend Parenting Arizona classes to develop anger management skills. Frequency- Attend at least 1 class/week for minimum of 8 weeks Specific Service - Meet with Voc. Rehab. Counselor to update resume. Frequency - As needed Specific Service - Meet with Housing Support Services to apply for rental assistance. Frequency - One time Specific Service - Talk to social service group at church and volunteer in their food pantry. Frequency - Volunteer 1x/week

  35. The Service Plan:Strengths Used Strengths Used: Identify which member/family traits, abilities, resources, characteristics, etc. are to be utilized in addressing each objective. These can either be strengths that the client has identified, or strengths identified by members of their ART or CFT.When identifying strengths, consider the member’s culture, and such things as their: faith/religion, education, skills, abilities/talents, interests, etc.

  36. The Service Plan:Strengths Used >Mary's talent in art and ability to express feelings through art.>Jamie is willing to fully engage in therapy.>Rafael has friends in recovery he is willing to call anytime.>Brian is motivated to do what it takes to be a better father.>Rick has a few good friends who have been supportive in the past.>Stella has a good knowledge of bus system and ability to use it. Strengths Used - Examples:

  37. The Service Plan:Review Date Review Date:The review date should reflect the date when the member’s Service Plan will next be reviewed and likely updated by the Team members. The review date should coincide with the date by which the person is expected to have met the specific objectives listed on the Plan.Typical review dates are 30, 60 or 90 days from the ServicePlan creation date.-for low needs members (i.e., only needs monthly medication review) the Review Date may be up to 6 months.- for higher needs members, or those at some type of crisis risk, the Review Date timeframe should be relatively short. Note: anytime a member’s situation or behavioral health changes significantly (i.e., attempts suicide; becomes homeless) the Service Plan can/should be updated as soon as possible, regardless of the Review Date.

  38. The Service Plan:Discharge Plan Discharge Plan:Like the rest of the Service Plan, the discharge plan is a living plan that can be changed as appropriate to the member’s situation. The discharge plan should be brief, specific and understandable to the member/family. It may include how a member/family/team knows that behavioral health services are no longer needed (a summary of the Recovery Goal), or when this specific Service Plan is complete. It might be what will let the team know that intensity of services can be decreased (discharge from the hospital) or it might be a summary of what will occur after the member is dis-enrolled from our system. If the member is in an Out of Home placement the discharge plan should include a plan for step down services. The Discharge Plan should be appropriate to the client’s situation. If the clinician feels that a Discharge Plan cannot be formulated at the current time, then it can be completed at a later time when it is more appropriate.

  39. The Service Plan:Discharge Plan Discharge Plan -Examples:DISCHARGE PLAN (add discharge date if known): Mary will be sleeping through the night without nightmares consistently. She will have met her probation requirements and will be better prepared to live on her own.DISCHARGE PLAN (add discharge date if known): Complete six weeks of education; trial to be held in February 2011. Have completed plans depending on outcome, 1 Plan in the event not sent to prison, 1 Plan in the event of sent to prison.DISCHARGE PLAN (add discharge date if known): Once all target goals and dates are met, Brian will be discharged from services.DISCHARGE PLAN (add discharge date if known): Joe will discharge to a foster home when he is able to demonstrate that he can engage in positive behavior and utilize more appropriate coping skills. Joe will discharge when he can demonstrate appropriate life skills and self-care with only minimal supervision and cueing from the HCTC provider.

  40. The Service Plan:Signatures > The Service Plan must contain all listed signatures with dates of signing!> Remember, in the event that a BHT completes the service plan, a BHP must review and sign the Service Plan. > If the member is undergoing Court-Ordered Treatment (COT), the member’s Behavioral Health Medical Professional (BHMP) must sign the Plan.> If the member is under 18 years of age, their parent or guardian must sign the Plan for the member. (It can be a nice touch to have the child/youth sign the Plan at the bottom of the page - this bolsters a sense of empowerment and buy-in).

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