Neal Adams MD MPHNeal Adams MD MPH

Ed Diksa Sc DEd Diksa Sc D

Sharon Kuehn MHRESharon Kuehn MHRE

Being Person-Centered…Being Person-Centered…Mapping the Road to Mapping the Road to

Recovery, Resilience and Recovery, Resilience and WellnessWellness

Training ObjectivesTraining Objectives Describe the treatment Describe the treatment

planning process, elements and planning process, elements and criteria as a roadmap to criteria as a roadmap to recovery and wellnessrecovery and wellness

Identify how emerging new Identify how emerging new frameworks of person-centered frameworks of person-centered recovery, resiliency and recovery, resiliency and wellness differ from past and wellness differ from past and current practice to guide the current practice to guide the plan of careplan of care

Training ObjectivesTraining Objectives Join in partnership with the client/ Join in partnership with the client/

family, develop and prioritize family, develop and prioritize objectives, interventions and objectives, interventions and services that reflect client/family services that reflect client/family strengths, preferences, choices and strengths, preferences, choices and stage of changestage of change

Define key elements of Define key elements of documentation (including Medical documentation (including Medical Necessity) and properly document Necessity) and properly document the elements of the plan and services the elements of the plan and services provided provided

President's MH President's MH CommissionCommission

Goal 2Goal 2 Mental Health Care is Consumer and

Family Driven Recommendation 2.1Recommendation 2.1

The plan of care will be at the core of the consumer-centered, recovery oriented mental health system

Providers should develop customized plans in full partnership with consumers

HypothesisHypothesis Person-centered treatment plans can Person-centered treatment plans can

be a be a key leverkey lever of personal and systems of personal and systems transformative change at all levels:transformative change at all levels: Individual and family Provider Administrator Policy and oversight

Building a PlanBuilding a Plan

Request for services

Assessment

Services

Understanding

Goals

Objectives

Outcomes

Prioritization

Barriers

What Do People Want? What Do People Want?

Commonly expressed goals of persons Commonly expressed goals of persons servedserved

Manage their own lives Quality of life Social opportunity Education Activity / Accomplishment Work Transportation Housing Spiritual fulfillment Health / Well-being Satisfying relationships

... to be part of the life of the community

Serving Two MastersServing Two Masters

Person-centeredPerson-centered Recovery Community integration Core gifts Partnering Supports self-direction

RegulationRegulation Medical necessity Diagnosis Documentation Compliance Billing codes

Outcomes and GoalsOutcomes and Goals

UnderstandinUnderstandingg

Plan DevelopmentPlan Development

Acquired skill / Art formAcquired skill / Art form Not often taught in professional training Often viewed as administrative burden and

paper exercise Requires flexibility

Opportunity for creative thinkingOpportunity for creative thinking Integrates information about person Integrates information about person

servedserved Derived from formulation and prioritization Information transformed to understanding

Strategy for managing complexityStrategy for managing complexity

Service Plan Functions Service Plan Functions Specifies intended outcomes / Specifies intended outcomes /

transitions / discharge criteriatransitions / discharge criteria Clearly elaborates expected results of services

includes perspective of person served and family in the context of the person’s culture

Promotes consideration and inclusion of alternatives and natural supports / community resources

Establishes role of person served and Establishes role of person served and family in their own recovery / family in their own recovery / rehabilitationrehabilitation Assures that services are person-centered Enhances collaboration between person

served and providers

Service Plan Functions Service Plan Functions continuedcontinued

Identifies responsibilities of team Identifies responsibilities of team members--members--including person served and including person served and familyfamily Increases coordination and collaboration Decreases fragmentation and duplication Coordinates multidisciplinary interventions Prompts analysis of available time and

resources Provides assurance / documentation of Provides assurance / documentation of

medical necessity medical necessity Anticipates frequency, intensity, duration of

services Promotes culturally competent servicesPromotes culturally competent services

Service Plan Functions Service Plan Functions continuedcontinued

Supports utilization managementSupports utilization management Services authorization, communication

with payors and payment for services Allocation of limited resource

A Plan is a Road MapA Plan is a Road Map

Provides hope by breaking a Provides hope by breaking a seemingly overwhelming journey seemingly overwhelming journey into manageable steps for both the into manageable steps for both the provider and the person servedprovider and the person served

A E

B C D

“life is a journey…not a destination”

A plan is only as good as the A plan is only as good as the assessmentassessment..

Cultural ElementsCultural Elements Person / provider relationship Person / provider relationship

shaped by differences in culture and shaped by differences in culture and social statussocial status

Impact clinical encounterImpact clinical encounter Communication Rapport Disclosure Privacy Trust Power Dignity Respect

Importance of Importance of UnderstandingUnderstanding

Data collected in assessment is by itself Data collected in assessment is by itself not sufficientnot sufficient for service planning for service planning

Formulation / understanding is essentialFormulation / understanding is essential Requires clinical skill and experience Moves from what to why Sets the stage for prioritizing needs and goals The role of culture and ethnicity is critical to true

appreciation of the person served Recorded in a chart narrativeRecorded in a chart narrative

Shared with person served

UnderstandingUnderstanding Identifies individual's and family’s Identifies individual's and family’s

strengthsstrengths Identifies stages of change/recoveryIdentifies stages of change/recovery It helps determine prioritiesIt helps determine priorities

Accounts for choice and preference Enables everyone to see the Enables everyone to see the

interrelationships in the person’s lifeinterrelationships in the person’s life It serves as the context for the planIt serves as the context for the plan It clarifies the order in which It clarifies the order in which

objectives need to be addressed – objectives need to be addressed – sequential or concurrentsequential or concurrent

FormulationFormulation

Makes assessment data meaningfulMakes assessment data meaningful Involves clinical skill Critical value added component of entire service

process Narrative summaryNarrative summary

A few paragraphs More than just a re-telling of history / facts

Provide synthesis, analysis, insight, hypothesisProvide synthesis, analysis, insight, hypothesis Can include diagnosis and rational

Becomes the basis of creating the planBecomes the basis of creating the plan Understanding the why leads to informed tactics

and success

The 9 PsThe 9 Ps

P P ertinent history ertinent history [[brief brief ]] P P redisposing factorsredisposing factors P P recipitating factorsrecipitating factors P P erpetuating factorserpetuating factors P P resent condition / presenting problemresent condition / presenting problem P P revious treatment and responserevious treatment and response P P rioritization by person servedrioritization by person served P P references of person servedreferences of person served P P rognosisrognosis

Vignette--CarmenVignette--Carmen

18 year old Latina18 year old Latina High school senior

preparing for graduation First generation

parents monolingual Spanish speaking client bilingual observant Catholic family

Lives in predominantly Anglo-American community

Vignette Vignette continuedcontinued

Excellent studentExcellent student Active in school and social activities Recently unable to attend school because of

distress Graduation from high school and college

attendance is core value for Carmen and family

Recent physical problems Nausea, vomiting, dizziness, headaches

Parents believe she is suffering from susto Treatment from curandero

Vignette Vignette continuedcontinued

Recent crisisRecent crisis Acute physical distress Admitted to hearing a baby cry while at

school Reported feeling sad and blue

Referred to mental healthReferred to mental health Embarrassed and resistant First family member to seek MH services

Vignette Vignette continuedcontinued

Assessment with Latina provider in Assessment with Latina provider in SpanishSpanish Revealed she had a miscarriage a year ago Feeling increasingly guilty and troubled Wants to die and join her baby Relationship with parents has become

distant and conflictual father refusing to speak with her

Vignette FormulationVignette Formulation IdentityIdentity

First generation Latina Bilingual

Explanation of IllnessExplanation of Illness What appeared to be a physical problem is a

mental health problem somatization is idiom of distress shame, guilt and embarrassment are key

themes Provider relationshipProvider relationship

Spanish preferred More open with Latina clinician

Vignette FormulationVignette Formulationcontinuedcontinued

Psychosocial environmentPsychosocial environment Lives with family, first generation Some degree of acculturation and distance

from parents difficult and painful

DiagnosisDiagnosis Consider possibility of culture bound

syndrome Susto

Possible depression with psychotic features Understanding her beliefs may be key to

treatment

Vignette FormulationVignette Formulationcontinuedcontinued

HypothesisHypothesis Intergenerational issues of acculturation are

a major factor Age appropriate issues of individuation and

separation She is between contemplative and active

stage—some ambivalence about help-seeking

School completion and education opportunity and advancement are shared values /strengths to build upon

Need to help her reconcile feelings of guilt and remorse

Religious and spiritual factors may be significant

GoalsGoals Long term, global, and broadly statedLong term, global, and broadly stated

The broader the scope the less frequently it needs to change

Perception of time may be culture bound may influence expectations and participation may need to explain type and / or level of

service

Life changes as a result of servicesLife changes as a result of services Focus of alliance / collaboration Readily identified by each person

Linked to discharge / transition Linked to discharge / transition criteria and needscriteria and needs Should describe an end point of helping

relationship

Goals Goals continuedcontinued

Person-centeredPerson-centered Ideally expressed in person served’s / family’s

words Easily understandable in preferred language Appropriate to the person’s culture

reflect values, life-styles, etc. Consistent with desire for self-determination

and self-sufficiency may be influenced by culture and tradition

Three typesThree types Life goals Treatment goals Quality of life / enhancement goals

Goals Goals continuedcontinued

Essential featuresEssential features Attainable

one observable outcome per goal Realistic Written in positive terms

built upon abilities / strengths, preferences and needs

embody hope alternative to current circumstances

Carmen’s Plan Carmen’s Plan

GoalGoal “I want to graduate from high school”

BarriersBarriers

What is keeping the person from their What is keeping the person from their goals?goals? Need for skills development Intrusive or burdensome symptoms Lack of resources Need for assistance / supports Problems in behavior Challenges in activities of daily living Threats to basic health and safety

Challenges / needs as a result of a Challenges / needs as a result of a mental / alcohol and drug disordermental / alcohol and drug disorder

ObjectivesObjectives Work to remove barriersWork to remove barriers

Must be active and positive Culture of persons served shapes Culture of persons served shapes

objectivesobjectives Important to address culture bound barriers

Expected near-term changes to meet Expected near-term changes to meet long-term goalslong-term goals Divide larger goals into manageable tasks

risk of being too trivial or to grand Provide time frames for assessing progress Maximum of two or three per goal recommended

ObjectivesObjectives

Build on strengths and resourcesBuild on strengths and resources Essential featuresEssential features

Behavioral Achievable Measurable Time framed Understandable for the person served

Services are not an objectiveServices are not an objective

Objectives Objectives Appropriate to the setting / level of Appropriate to the setting / level of

carecare Responsive to the person’s individualResponsive to the person’s individual

disability, challenges and recoverydisability, challenges and recovery Appropriate for the person’s age, Appropriate for the person’s age,

development and culturedevelopment and culture ““Dead man standard”Dead man standard” ““The individual / family will …”The individual / family will …”

Changes in behavior / function / status Described in action words

Carmen’s Plan Carmen’s Plan

GoalGoal “I want to graduate from high school”

ObjectiveObjective Carmen will return to class attendance for 5

consecutive full days within a month as reported by Carmen / or support worker

InterventionsInterventions ActionsActions by person served, family, peers, by person served, family, peers,

staff and and the entire system of carestaff and and the entire system of care may include family, support network, etc.

Specific to an objectiveSpecific to an objective Cultural efficacy must be consideredCultural efficacy must be considered Availability and accessibility of services Availability and accessibility of services

may be impacted by cultural may be impacted by cultural factorsfactors

Six Critical ElementsSix Critical Elements

Interventions must specifyInterventions must specify Provider and clinical discipline Staff member’s name Modality Frequency /intensity / duration Purpose / intent / impact

Clarifies who does whatClarifies who does what Include a task for the client and/or Include a task for the client and/or

family, or other component of family, or other component of natural support system to natural support system to accomplishaccomplish

Carmen’s PlanCarmen’s Plan Sample interventionsSample interventions

Psychiatrist to provide weekly to monthly pharmacotherapy management visits for 3 months to relieve acute symptoms of anxiety and depression

Social worker to provide one hour of cognitive-behavioral psychotherapy twice a week for 4 weeks to help Carmen resolve feelings of guilt and loss

Support worker to meet with Carmen up to 3 hours / week for 4 weeks as required to coordinate / facilitate return to school with school counselors and mental health team

Carmen to attend teen support group at community center weekly for 3 months to address with peers issues of identity and acculturation

Review / EvaluationReview / Evaluation Reassess plan at clinically Reassess plan at clinically

appropriate intervalsappropriate intervals Determine effectiveness Re-evaluate appropriateness Input of person served / family essential

Plan revisionsPlan revisions Concerns / needs Formulation Goals / discharge Objectives Interventions / modalities Time frames and target dates

Common MistakesCommon Mistakes

AssessmentAssessment Do not use all available information

resources Not culturally appropriate / sensitive Not sufficiently comprehensive Lack adequate integration /

understanding of the person

Common MistakesCommon Mistakes

GoalsGoals Not global Not directed towards recovery Not responsive to need Not strengths based Too many

Common MistakesCommon Mistakes

ObjectivesObjectives Don’t support the goal Not measurable or behavioral Interventions become objectives Not time framed Too many simultaneous objectives

Common MistakesCommon Mistakes

InterventionsInterventions Purpose not included Frequency, intensity, and duration not

documented Too few Don’t reflect multidisciplinary activity

““If you don’t know where you If you don’t know where you are going, you will probably are going, you will probably

end up somewhere else.”end up somewhere else.”

Lawrence J. PeterLawrence J. Peter