P E R M I A N B A S I N C O M M U N I T Y C E N T E R S F O R M H M R

B R I D G E S B E H AV I O RA L H E A LT H C L I N I C

I N T E G RAT E D P R I M A RY C A R E C L I N I C

C A S E M A N A G E M E N T:E N C O U N T E R D O C U M E N TAT I O N

P R E S E N T E D BY R I C A R D O O . H E N RY, M A , T L B R I D G E S I P C - M I D L A N D

NATIONAL ASSOCIATION OF STATE MENTAL HEALTH PROGRAM DIRECTORS (NASMHPD)

• “a range of services provided to assist and support individuals in developing their skills to gain access to needed medical, behavioral health, housing, employment, social, educational and other services essential to meeting basic human services; linkages and training for patient served in the use of basic community resources; and monitoring of overall service delivery” (NASMHPD [2014]).

WHAT IS CASE MANAGEMENT?Case management includes:• comprehensive assessment of needs

and resources,• development of a care plan, referral

follow-up, • periodic evaluation of the plan• aimed at helping the client achieve

their established treatment goals

NEEDS• Medical Health• Behavioral Health• Social

– Housing– Employment– Finance– Nutrition– Social Skills

• Social & Community Services• Other Services

ASPECTS OF CASE MANAGEMENT• Identification (Walk-in/ Referral) • Assessment or Evaluation (Screening)• Development of Care Plan*• Symptom Management

(Physician/Therapist)• Follow-up

– Monitoring– Reassessment– discharge

ENCOUNTER INTERVIEW

ENCOUNTER INTERVIEW• The quality of the encounter documentation is affected by to the quality of our interview• The quality of the Case Management Interview is affected by the quality (skill) of the case manager• The quality of the case manager is affected by the quality of experience (training and practice) of the case manager

BEHAVIORAL HEALTH SCREENING• Brief history of symptoms• Past and current treatment•Description of effect of symptoms• Evaluation of cultural and linguistic needs• Evaluation of social support• Evaluation of available benefits• Signed Consents

TELEPHONE ENCOUNTER•Medication•Mental Wellness•Requests •Information

POTENTIAL RESOURCES• PBCC Programs / Units including BBH• HHSC• Midland / Ector County Housing (Section 8)• Midland / Odessa Housing Authority (City)• Goodrx.com• Rxassist.org• Churches & Civic Groups• Drug Manufacturers

POTENTIAL EDUCATION ITEMS•Medication•Nutrition• Exercise• Symptoms Management Self Help• Community Services available

–Eg. WTO Transportation support for medical appointments

CASE NOTESC A S E M A N A G E M E N T E N C O U N T E R S

WHY CASE NOTES?•Accountability•Professional and Ethical Responsibility• Information Sharing•Memory Aid•Liability

NOTES FORMAT

• DAP = Data Assessment Plan (PBCC Format)

• SOAP = Subjective, Objective, Assessment, Plan

WRITING THE NOTESInclude: Description of the context Purpose of the conversation Observations Content Outcome Impression and assessment of the person or situation Plans

DO’S & DON’TS• Do make them clear and concise

• Do make them accurate and complete

• DO make them legible

• DO use the THIRD PERSON

• Do not emotional reactions or value judgements

• Do not record unsupported suspicions, commentary,

opinions

• Don’t write with vagueness (be specific)

• Do not create your own diagnosis

QUALITY TEST

Could a colleague use my case notes to determine the next steps to help

the patient?If the patient read your case notes would s/he feel respected and

would s/he agree with your record of

the interaction?

CASE MANAGEMENT NOTES• Identify ALL case management activities by recording items discussed. •Describe and smartly query mood and demeanor during and at the end of the session• Record mental status observation

AMSIT

• Appearance, Behavior, and Speech•Mood and Affect• Sensorium• Intellectual Function• Thought

SOAP

•Subjective – Patient’s report•Objective – Case Manager’s/ Observers report•Assessment – Clients Progress•Plan – Future Planning

CASE MANAGEMENT HABITS•Monthly check on ALL case files•Check referrals weekly•Check PAP med list weekly•Review Resources List Annually

SOAP NOTE - SAMPLE• TC met with Felix for a scheduled home visit

today. Felix said things were going well. The home was clean. The appliances were in well working order. Felix appeared very happy in his new apartment. TC reviewed the 24-hour back-up plan and personal resource list with Felix. TC discussed budgeting with Felix. Felix shared his utility bills with TC. TC reviewed medication list with Felix. Felix stated he was at the doctor’s last week and the doctor changed some of his medications around. TC updated Felix’s medication sheet. TC told Felix she would be back next Tuesday to visit him. Felix stated he didn’t need anything else, but he would call her if you needed something before their next visit together.

PRACTICE MAKES PERFECT & PERMANENTS C E N A R I O S

• Scenario 1- Situation: Student is talking one on one with you

I feel really tired. I have these early classes and sometimes I just can’t get out of bed in the morning. I try to do all my readings but they just don’t sink in, even after reading them over and over. I try so hard at the work, but I’m not getting very good grades. I just don’t think I get it… like I have this group project for class and everyone in my group is so smart and I don’t think my part is going to be any good. I just feel helpless… and I can’t talk to my family about it because my brother’s at school right now on a full scholarship and he’s getting great grades. I feel so guilty because my parents had to pay for everything for me because I couldn’t find a summer job… and my family doesn’t have a lot of money right now. If I loose my entrance scholarship, they’re going to be so disappointed. Most of the time I just feel alone… all my friends went to other universities… they have new friends and their own work and don’t want to hear about my problems.

• A 30-year-old female patient was referred to this office by her primary care physician for a psychiatric evaluation. She presents with complaints of worriedness, nervousness, frequent cold sweats, and tiredness, trouble concentrating especially at work, sleeplessness, hopelessness, loss of appetite, sadness, and occasional suicidal thoughts. A comprehensive psychiatric evaluation and interview was conducted. During this process, a detailed personal history of development, life events, emotions, behaviors, and the identified stressful events are obtained. A stressful event identified is that her parents separated when her mother became severely ill with stage 4 colon cancer. She became the care-giver and primary provider at the same time. She is diabetic and history of high blood pressure

A 68-year-old male established patient diagnosed with anxiety comes in today for a follow-up. Patient has been struggling lately with recall and has been gaining weight rapidly. He currently takes Paxil CR one a day for his anxiety. Anxiety appears well controlled on current medication.