Treatment Planning for Person-Centered Care: The Road to Mental Health and Addiction Recovery

Treatment Planning for Person-Centered Care

The Road to Mental Health and Addiction Recovery

Neal Adams, MD, MPH

Diane Grieder, MEd

Table of Contents

Cover image

Title page

Copyright

Acknowledgments

Prologue

Foreword

Preface

SECTION I: Planning the Trip

Introduction to Planning the Trip

Chapter 1: Introduction: Planning the Trip

I. STATING THE CASE

II. CREATING THE SOLUTION

III. MAKING IT HAPPEN

Chapter 2: Person-Centered Care

I. STATING THE CASE

II. CREATING THE SOLUTION

III. MAKING IT HAPPEN

Chapter 3: The Value of Individual Planning

I. STATING THE CASE

II. CREATING THE SOLUTION

III. MAKING IT HAPPEN

SECTION II: Getting Started

Introduction to Getting Started

Chapter 4: Assessment

I. STATING THE CASE

II. CREATING THE SOLUTION

III. MAKING IT HAPPEN

Chapter 5: Understanding Needs: The Narrative Summary

I. STATING THE CASE

II. CREATING THE SOLUTION

III. MAKING IT HAPPEN

SECTION III: On the Road

Introduction to On the Road

Chapter 6: Setting Goals

I. STATING THE CASE

II. CREATING THE SOLUTION

III. MAKING IT HAPPEN

Chapter 7: Focusing on Change: Specifying the Objectives

I. STATING THE CASE

II. CREATING THE SOLUTION

III. MAKING IT HAPPEN

Chapter 8: Interventions

I. STATING THE CASE

II. CREATING THE SOLUTION

III. MAKING IT HAPPEN

SECTION IV: Journey’s End: The Destination

Introduction to Journey’s End: The Destination

Chapter 9: Evaluating the Process

I. STATING THE CASE

II. CREATING THE SOLUTION

III. MAKING IT HAPPEN

Epilogue

APPENDIX A: CHILD DIAGNOSTIC ASSESSMENT

APPENDIX B: ADULT DIAGNOSTIC ASSESSMENT

APPENDIX C: COUNTY MENTAL HEALTH—MULTIDISCIPLINARY INTAKE ASSESSMENT (RE-ADMISSION)

Appendix D: PINE GROVE MENTAL HEALTH CLINIC INTAKE ASSESSMENT

Index

Copyright

Elsevier Academic Press

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Acknowledgments

As all authors note, this book could not have been written without the assistance and support of many people. Similar to the team assisting the individual to achieve his or her goals in the person-centered approach, we have also had a team accompanying us on our first book-writing journey. Sincere thanks to our editor, Nikki Levy, who warned us, writing a book will be the hardest thing you ever do, and she was right!

Many thanks to our colleagues who were willing to read, offer comments and support, and even edit portions of the book as it evolved: Ed Diksa, Wilma Townsend, Nirbay Singh, John Morris, Lesa Yawn, Nikki Migas, Wendy Graddison, Yana Jacobs, Penny Knapp, Sherry Kimbrough, and James W. Baxter.

Thanks are also due to the many individuals receiving services we have met in our professional careers, who have been a source of inspiration to us. They have taught us how to listen, to have hope, and to believe in them.

Most importantly, thanks to our respective families, who joined us on this road trip—sometimes willingly, sometimes not—and were the fountains of support, encouragement, understanding, and forgiveness that made writing this book possible. To our spouses, Lucy and Marion, and to our children, Alyssa, Caleb, Parris, and Zachary, we will be forever grateful.

Prologue

Providers should consider this book one of the most important instructional tools in the field of mental health and addictive disorders. As an individual who began her professional life as a case manager, who later moved into administration and management, and who now works as a consumer advocate and consultant, I know that there has traditionally been little practical teaching about how to develop a treatment plan, or why it is important beyond its role in financial reimbursement. The value of a plan as a road map to assist the individual in their treatment process was never considered. There is a real need for a book that can assist all participants in mental health and addiction recovery to master the skills of a person-centered approach to developing individual plans.

Later, in my capacity as the chief of the Office of Consumer Services within the Ohio Department of Mental Health, the importance of an individual plan was immediately germane to our discussions about what is recovery? This in part led to the development of the booklet Emerging Best Practices in Mental Health Recovery¹. That book was the result of work by consumers, families, clinicians, and researchers who studied the consumer’s recovery process and the role of providers and the community in assisting them. Emerging Best Practices also led to the development of a curriculum on Clinicians Facilitating a Consumers Recovery Process, which supported the development of a recovery management plan (RMP)/treatment plan. We found that language is crucial in the recovery process; changing the name of the document put the focus on the individual instead of putting the focus on the illness, as the term treatment plan seemed to do.

I have since left the Department of Mental Health and have been working with behavioral health systems on the implementation of the Emerging Best Practices in Mental Health model. This includes a very specific structure to assist providers and consumers in implementing person-centered care. I have trained providers and consumers, sometimes together, on this structure. I have also guided them in the journey of putting this process and form into practice. The journey is the individual’s journey, so the individual must be the one who makes the final choices. In making these decisions, it is important that there is a structure to promote a dialogue between the individual and the provider about possibilities and choices. The creation of a person-centered plan can provide that structure and help the individual, in partnership with the provider, to identify long- and short-term goals for the consumer to work towards with their caregivers.

An RMP is a person-centered plan. In an RMP, all goals are written in both clinical terms as well as layperson language so that both the consumer and provider can relate to aspects of the RMP from their own perspective. Using the individual’s own words, the RMP helps to identify the skills, knowledge, and action steps/interventions necessary to meet the goals. It also provides an opportunity for the individual to identify activities in the community that they want to pursue or organizations in the community can assist them in accomplishing their goals. The individual and the provider then decide how the provider can best assist them in accomplishing their goal. Oftentimes the RMP is actually completed by the individual, who is then given a copy to take home.

This process is all about helping the individual make decisions rather than the provider being the decision-making authority. It is about the individuals taking on more responsibility in their own recovery processes. Over time the individual will better understand that his or her illness is just one dynamic in their life. It is about enabling both the provider and the individual to recognize that in order to live, work, and have a meaningful life in the community, individuals must learn to make decisions for themselves and not rely forever on 24/7 supports. It is the individual’s life to be lived.

In attempting to introduce these new approaches to established practice settings, many providers typically respond by saying: …but we are already doing this (i.e., person-centered planning). It is only after being trained and practicing this process that they realize it is really quite different. They realize that in the past they have not used a structure that truly enabled the individual to express and fulfill his or her partnership role in treatment and recovery. Providers come to realize that the individual needs to more actively exercise options and choices, make decisions, and be accountable for his or her actions. Providers see, in contrast, how they have been unwittingly making decisions and directing care.

After several years of experience in many different sites and settings, it is clear to me and others that a person-centered approach can and does make a real difference for individuals and supports their growth and recovery (see the epilogue for a collection of individual recovery stories). Providers who have developed skills in person-centered planning appreciate the importance of treatment plans beyond reimbursement and administrative requirements. The real goal of person-centered planning is for the provider and individual, in partnership, to create a road map for reaching the individual’s goals—and at the same time documenting medical necessity and supporting billing.

Not only am I a provider and trainer, I am also a person who has received services within the behavioral health care field and whose provider used a person-centered approach to planning and creating my personal road map to recovery. Because of this, I felt like I was a part of the process, that the process was about my recovery and me, and I was able to truly benefit from services.

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

Wilma Townsend

¹Ohio Department of Mental Health, 1999.

Foreword

This book offers an exciting, dynamic, and fresh approach to the challenges of developing individual plans for mental health and addiction services. Our goal is to help make planning a manageable task for providers, a meaningful process for individuals receiving services, and a resource tool to assure person-centered care and optimal outcomes.

It should be clearly stated at the outset that this book is not a how-to manual for completing forms. Rather, the focus should be on the process of using the service plan to build effective and collaborative healing partnerships with individuals and families in pursuit of resilience, wellness and recovery.

This book was written with a focus towards relevance for all providers and settings, ranging from traditional one-to-one approaches in private practice to multidisciplinary teams in community care organizations or residential and inpatient facilities. Using a practical approach, rich with examples adapted to a wide range of adult learning styles, it is intended to be suitable and valuable for an independent reader or classroom learning. The book is intended to help students and experienced providers improve their ability to develop person-centered plans that enhance the value and efficacy of services. In this way, providers will be better able to develop an individual plan that optimizes outcomes for the individual as well as meet the requirements of payers, accreditation standards, regulatory bodies, and so on.

We believe that there is also a need for this kind of text for students in pre-degree training programs as well as for established professionals who want to respond to important changes and trends sweeping through all of health care. Service recipients, families, advocates, policy makers, and others should all find useful information and resources in these chapters.

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 a diagnostic label), person involvement (the individual’s right to participate in all aspects of the service, including designing the individual plan, and implementing and evaluating services), 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), and growth potential (given the opportunity and necessary resources, the inherent capacity of any individual to recover, grow, and change).

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 a 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.

This book attempts to blend a commitment to recovery, resiliency, and wellness with a practical, simple, and straightforward approach so that all readers—from students to providers—will develop the skills that they need to write effective plans. The various sections include strategies, tips, and sample plans and forms, as well as illustrative examples to help practitioners succeed in the ever-evolving health care delivery system.

To help the reader more easily access the information in this book, there are several layers of content focus, with the chapters organized into four sections. Each section describes the various phases of a trip; seeing the pursuit of wellness and recovery as a journey is a useful way of thinking about the steps and processes that need to be considered in developing a person-centered plan.

With this metaphor in mind, an individual plan can easily be thought of as a map. Few people begin a journey without some sense of destination and at least a preliminary route. Together, the individual seeking services and the provider develop the individual plan (map) that will hopefully lead to the recovery goal or outcome (destination) the individual wants to achieve. The intermediate steps are the objectives of the individualized plan (sites to visit along the trip). The services/interventions (route) help assure that each intermediate step is reached.

In addition, each chapter is organized into three parts:

• Stating the Case

• Creating the Solution

• Making It Happen

Stating the Case is a look at the status quo as well as emerging trends in both theory and practice. Creating the Solution presents the essentials of a person-centered approach to preparing and implementing individual plans. Making It Happen includes examples of plans as well as strategies for changing systems and practices.

As all travelers know, a map is an indispensable tool to help guide the journey. Thinking about individual planning as a trip to be mapped helps us to better explore and understand the process. Ultimately, creating a plan is about helping an individual to envision their own journey (creating a map that directs their trip). At the same time, our ability to be helpful and stay on track is enhanced by having the course laid out and the destination identified.

Bon voyage!

Neal Adams, MD, MPH and Diane Grieder, MEd

Preface

The use of language is often anchored in history, tradition, assumptions, and values. Words communicate ideas that go beyond the terms and phrases themselves. But this is by no means static; there are trends and periodic shifts that impact how we think and understand the world around us and help to shape the work that we do. Accordingly, a few comments about language must precede the text that follows.

Our desire is to make this book as useful and relevant as possible to the needs of the broadest audience without being limited to any particular practice model, philosophy, or professional discipline beyond a commitment to person-centered care. This requires the thoughtful use of language and an attempt at neutrality. While there are those who decry as well as those who celebrate political correctness, there is no question that the use of language can either engage, distract, or even repel a reader. After considerable discussion, we elected the following lexicon to use in discussing the principles and practice of developing plans to meet the needs of individuals and families receiving services.

For the focus of this book itself, the plan is often referred to as an individual treatment plan, an individual services plan (ISP), a consumer services plan (CSP), an individual recovery management plan (RMP), an integrated plan, a service coordination plan, and so forth. For our purposes, we have settled on the simple term individual plan, which stresses the notion of person-centeredness.

We use the term individual to refer to patients, clients, residents, members, users, consumers, and persons served. Some words imply passivity, while others connote participation. Language that respects the dignity as well as unique attributes and needs of all people is critically important. Oftentimes throughout the book, references to the individual are tied to the family. For children and adolescents, it should be a given that is always implied, if not explicitly stated, that family is essential to understanding and responding to the needs of the individual. For adults, it is recognition of the important role that family plays in all of our lives—for better or for worse. Family may be defined in traditional terms or may be a constellation of relatives and friends determined by the individual. Regardless, that essential support network commonly referred to as family should almost always be considered in planning mental health and addiction services.

We have chosen the term services to refer to what in some settings might be called treatment, care, support, therapy, rehabilitation, and so forth. Recognizing that there are different models, different philosophies and attitudes, and a range of professional disciplines and clinical traditions (including both licensed and degreed as well as paraprofessional and peer providers), we felt that services was the most neutral and inclusive term to use at this time.

The term narrative summary is used within this book to describe what might be called an interpretive summary, diagnostic summary, or clinical formulation. It is an essential but often overlooked part of assessment and planning which attempts to create meaning and relevance from the factual database of the assessment. Understanding each individual and their unique circumstances and needs should be clearly articulated and documented.

Additionally, we settled on the term provider to describe people frequently referred to as doctor, clinician, counselor, therapist, psychologist, case manager, nurse, aide, caregiver, treatment team, self-help peer, and so forth, working in a wide range of settings. All of these roles and titles hold in common their service to people in need of assistance and support.

Alternatively referred to as a chart, medical record, documentation, client or patient record, electronic record, health information, and so forth, we felt that the simple term record was sufficient. Regardless of format or organization—from 19th century pen and paper to 21st century data systems—creating and maintaining a record of our assessments, our understanding, the plan of action, and services provided remains a key part of our job.

The idea of recovery is referenced throughout the book. This is an emerging concept in mental health and reflects a new way of thinking about the impact of services and the importance of individual goals and outcomes. Wellness, resiliency, and rehabilitation are among many other terms often used interchangeably. At the same time, the term recovery has had long-standing use in the addiction treatment field where it conveys a lifelong process of facing one’s challenges and vulnerabilities. We believe that the idea of recovery should be a central theme and shared universal goal for all of mental health and addiction services.

We recognize that not everyone will necessarily agree with our choices. At the same time, we hope that no one will find them off-putting or offensive. We trust that each reader can translate these terms into those words and phrases that best fit their own perspective, philosophy, setting, and work. Hopefully the values and principles that follow will prove durable and transcend the limitations and constraints of language.

We have written this book based upon our collective years of study and practical experience in the field as providers, trainers, administrators, surveyors, and consultants. Too often we have seen quality programs and top-notch providers fall short of their potential to succeed and excel because of problems in individual planning. Too often we have witnessed individuals in need of help disappointed and frustrated at not receiving the services and benefits they need and deserve. Our belief is that effective and meaningful planning for service delivery does make a difference.

We have had the satisfaction of seeing providers, along with individuals receiving services, celebrate their shared satisfaction and success when lives are changed and people achieve their own vision of wellness, resilience, and recovery. This book is dedicated to and reflective of our commitment to the spirit that makes us each uniquely human. Its inspiration lies in understanding the power of one person’s care for another, and the value of thoughtful planning as we work to help those who ask for our assistance.

SECTION I

Planning the Trip

Introduction to Planning the Trip

The essential task in planning this journey of discovery and learning is to fully understand the relevance and importance of individual plans in contemporary mental health and addiction recovery practice, regardless of the setting or population served. Similar to the earlier stages of considering a trip, this section provides both history and background along with an overview of current trends and issues in assessment, individual planning, and documentation.

The notion of person-centered care was once a defining feature of rehabilitation approaches. Now it is no longer isolated to rehabilitation practice. The importance of person-centered approaches to care is reshaping practice throughout health care. Understanding what is meant by person-centered care, and clarifying the role of both the provider and the person served, are crucial to successful planning and outcomes.

At the end of this section, the importance, value, and relevance of undertaking this trip should be clear. Then, knowing the destination, the traveler can make the necessary plans and prepare for the beginning of the journey.

CHAPTER 1

Introduction: Planning the Trip

When you’re finished changing—you’re finished.

Benjamin Franklin

I. STATING THE CASE

What does it mean to be person-centered? What are recovery and resiliency? What is the role of the individual plan? These are critical questions challenging all health care providers at the dawn of the 21st century, and they are especially important for both providers and individuals seeking mental health and addictive disorders services. There is a growing consensus that current service delivery systems are failing to meet the needs of society as well as of individuals and families. Changing current practices in service planning can be a powerful strategy for effecting overall systems change. Ensuring that individuals and families are at the center of the process and directing their own plans and care should be an essential component of transformation in health care delivery. The challenges of daily work and the experience of providers in mental health and addictions stand in contrast to those concepts. Across all of the disciplines, providers frequently complain about feeling overwhelmed by a host of demands that keep them from their primary task of providing services. Consistently, the task of developing individual service plans is identified as the most clinically irrelevant, meaningless, frustrating, and mandatory administrative burden providers face. Training in this necessary task is often minimal and skill levels are low. Most direct care providers would likely groan in protest at the mention of attending training on individual planning, or the necessity of having up-to-par clinical documentation.

How can the individual plan simultaneously be viewed as a key element of systems transformation and be so disdained by providers? Why was reform of current planning practice identified as a major goal in the President’s New Freedom Commission on Mental Health report?¹ Is there any evidence that person-centered planning really improves the individual and family experience of care, promotes effectiveness, and enhances outcomes?

The History

The requirements and expectations for individual planning are long-standing and well established in regulation, payer requirements, and clinical standards. Despite this, auditors for licensure and certification, accreditation surveyors, and quality improvement staff consistently find that individual planning practices fall short of expectations. For example, CARF…The Rehabilitation Accreditation Commission, a leading standards-setting organization in the mental health and addictive disorders fields, has found that accreditation standards related to assessment and individual planning are cited in over 40% of accreditation surveys. Frequently identified problems include the lack of adequate assessment data, limited analysis or integration of information, uncertainty about goals and objectives, confusion about the differences between objectives and services, and inconsistent participation by the individual and the family receiving services.

While there is a general lack of study and evidence on the impact and value of individual planning, the practice may be so well accepted and expected simply because it has compelling face validity. In many sectors of our society, planning is a routine activity and a prerequisite for action. The quality of outcomes is often understood as a reflection of the integrity of the planning process and the quality of the plan itself. In general, the greater the complexity of a task that is undertaken, the greater the attention that is applied to the planning process.

Architecture is an example of a profession in which planning activities are essential to the practice, and the central role of the client is understood. Although the client may lack the professional and technical ability to design and construct a building, the architect understands that it is his or her role to make sure that the client’s needs, wishes, and dreams are included in the planning process. It is a given that the client’s expectations will be clearly visible in the final outcome.

It is not clear why the culture of the mental health and addictive disorders field has evolved so differently, but we can easily speculate. The tradition of psychiatry and mental health treatment derives from psychoanalytic practice, in which the emphasis was chiefly on process rather than outcome. As planning implies movement to an identified end point or goal, a process-driven approach did not necessitate nor lend itself well to planning. However, as systems of care became more organized, and as payers and oversight organizations began to demand more accountability for services and outcomes, there were increased expectations for coherent and visible planning. Yet some of the implicit values and expectations of the field and the traditions of practice were antithetical to the idea of planning. Moreover, the skill and motivation to teach and practice a planned approach to services did not exist.

In the addictive disorders field, the emphasis has been on