BTA is pleased to offer Staff Development programs addressing some of the most pressing quality and accountability issues in today's Public Behavioral Health Care Services.
TREATMENT PLANNING
and CLINICAL DOCUMENTATION
In-Service Training Options
presented by
Stan Taubman, PhD, LCSW
Director, Berkeley Training Associates
OVERVIEW
Medi-Cal, like many other insurance programs, takes the position that medically necessary services are those in which...
are focused on addressing…
- IMPAIRMENTS IN FUNCTIONING or DEVELOPMENTAL PROBLEMS (in children)
which are due to a…
This simple formula becomes difficult to implement when...
- Staff need better grounding in symptom description.
For example, many staff have difficulty distinguishing illusions from delusions, or delusions from overvalued ideas, spiritual beliefs or culturally held beliefs, or obsessions from preoccupations, compulsions, or obsessiveness. Or they confuse the prodromal/residual symptoms of schizophrenia with the acute psychotic symptoms of schizophrenia...or the anxiety symptoms of PTSD with the hyperactivity of ADHD.
THE CONSEQUENCES: As a result documented diagnoses are not validated. The Assessment contains elements that are inaccurate or it is incomplete. The Treatment Plan based on such an Assessment is then out of sync with the client's actual distress and impairment which is addressed during sessions....so staff have difficulty linking Progress Notes to the Treatment Plan. Staff put little credibility in their colleagues' documented assessments and the clinical record loses value as a resource for continuity of care.
- Staff need better grounding in differential diagnosis.
For example, many staff confuse depressive episodes with depressive disorders, or think of depression as a diagnosis rather than developing a differential diagnosis among the dozen or more possible diagnoses for a person who is depressed. Other staff have difficulty distinguishing the distress associated with problems of living from the syndromes (specified clusters of symptoms) which constitute diagnosable mental disorders. Others fail to recognize a client’s various co-occurring disorders. NOS diagnoses may linger in the chart long after unrecognized evidence of a specific syndrome has emerged, and some programs settle into a small set of preferred diagnoses such as Adjustment Disorder which become overused when a client's symptoms are much better accounted for by another, unrecognized diagnosis.
THE CONSEQUENCES: As a result documented diagnoses are not validated in the clinical record. Staff colleagues as well as third party reviewers put little credibility in the documented diagnoses and, again, the clinical record loses value as a resource for continuity of care and weakens its case for Medical Necessity.
- Staff need better grounding in case formulation.
For example, many staff describe a client’s impairments in functioning but fail to distinguish between those that are due to symptoms of a mental disorder and those that are instead due to other biopsychosocial factors. Others may fail to identify or distinguish between those factors which cause, trigger, exacerbate and maintain the client’s symptoms or impairments.
THE CONSEQUENCES: As a result the clinical record fails to show which are the impairments in functioning or developmental problems which are due to symptoms of the covered diagnosis.
- Staff need better grounding in clinically meaningful treatment planning.
For example, many staff fail to distinguish between their goals for the client, their recommendations to the client, and the client’s goals for themselves. Many staff fail to recognize and act on their own ethical and clinical principles which support good treatment planning. Instead they develop pro forma, clinically meaningless treatment plans as nothing more than an exercise in regulatory compliance.
THE CONSEQUENCES: As a result treatment plan goals (objectives) are not specific, observable or measurable, or when they are stated in such terms they are not realistic or clinically meaningful. As a result treatment plan objectives are not referenced in Progress Notes because they do not really reflect the true nature of clinical services to the client.
Experienced Quality Improvement staff, Clinical Service Managers, and Administrators know from experience that policy directives and admonitions alone don’t resolve these kinds of problems. When there is a need for improved knowledge and skills, well formulated training is the solution.
BTA has worked with scores of County Behavioral Health service systems and service providers across California. We and our host organizations have seen clear evidence of significant change when staff are provided with the knowledge and skills resources needed to meet policy and regulatory expectations. The following are our two most popular In-Service Training Scenarios.
TRAINING SCENARIO 1
STEP 1: MENTAL STATUS EXAM WORKSHOP - an overview of diagnostic concepts and terminology relevant to determining a DSM diagnosis (for those staff who have not had prior MSE training or whose pre-test scores demonstrate a need for trainint). This can be presented as a three hour workshop.
STEP 2: DIAGNOSTIC DILEMMAS WORKSHOP - an overview of the most common errors in differential diagnosis. Emphasizes errors due to inattention to co-occurring disorders. Designed for staff already familiar with the full range of DSM diagnostic options. This can be presented as a one day (six hour) workshop.
STEP 3: TREATMENT PLANNING WORKSHOP - This workshop presents proper treatment planning as an evidence based pracice, consistent with the participants' own principles of ethics and good clinical practice, cultural competence, third party payor requirements, and findings of scientific studies of treatment efficacy. Participants are presented with an overview of case formulation, cgoals, objectives, selection of intervention strategies by diagnosis, goals, and selectioin of a sequence of objectives related to reducing relevant functional impairments, including integrated treatment of co-occurring disorders.
This workshop may be used to introduce staff to the BTA Treatment Plan Documentation Guide for Use in Public Behavioral Health Care Services, at the discretion of the Department. For more information about this useful clinical reference guide, click on the link listed at the bottom of this page.
TRAINING SCENARIO 2
STEP 1: TREATMENT PLANNING WORKSHOP: In service systems where experienced staff are well versed in symptom description and differential diagnosis, the training begins with a full day workshop on Case Formulation and Treatment Planning. As in Scenario 1, staff are familiarized with treatment planning as an evidence based practice, consistent with the participants' own principles of ethics and good clinical practice, cultural competence, third party payor requirements, and findings of scientific studies of treatment efficacy. Participants are presented with an overview of case formulation, goals, objectives, selection of intervention strategies by diagnosis, goals, and selection of a sequence of objectives related to reducing relevant functional impairments, including integrated treatment of co-occurring disorders. The BTA Treatment Planning Guide may be used by staff for follow-up application of workshop principles in their actual practice.
STEP 2: CASE CONSULTATIONS: Follow-up Case Consultations are held with small groups of staff. Staff present their actual case documentation which is then evaluated acording to the explicit princiiples that were covered in the workshop. Half of the cases are selected because they are considered to be good examples of proper treatment planning. The other half of cases are selected because they are considered to be too complex or problematic to allow for clinically meaningful or compliant treatment planning. The focus is on principles of clinically meaningful treatment planning. Consistently, staff find that when these principles are met the Medical Necessity and documentation requirements of third party payors are invariably met as well.
