Service and Treatment and Planning

Core Principles of Assessment and Planning

Assessment and Planning for Mental Health services is a meaningful, ongoing process that helps identify an individual's recovery goals, current strengths and resources, needs, and barriers to recovery, including impairments in functioning. It is characterized by the following four values.

Strengths-Based

Strengths-based means recognizing and starting treatment with and individual's strengths, not with his or her deficits. As Charles Rapp put it in his 1997 book "The Strengths Model" it is "amplifying the well." While ARMHS eligibility is defined by deficits, treatment in ARMHS should be characterized by building on an individual's strengths, current resources, and resourcefulness.

Person-Centered

Person-centered means that the people we serve have control over their services, including the amount, duration, and scope of services, and choice of providers. Person-centered services respond to the needs of the individuals served as they have defined them and respect choices. Recipients participate in the development of treatment goals and services provided, to the greatest extent possible.

Most importantly, person-centered services means that we exhibit unconditional positive regard. We accept and embrace occasional ambivalence and, with empathy and compassion, understand undesirable choices and behavior as symptoms of illlness.

Recovery-Focused

For a working definition of recovery from SAMHSA, the Substance Abuse and Mental Health Services Administration read this article now. It is this definition around which we have developed our treatment model at Accend.

Goal-Oriented

Goals are positive, desired outcomes we are striving toward, not undesired current or previous conditions we are trying to avoid. In goal-oriented services, we help each individual we serve identify their wants, and needs, goals, hopes and dreams, form these into positive goals and then go about making a plan to achieve them. And we measure success as progress toward these goals.

Goals

More than likely, during your first meeting with a person referred to your services, you ask a question like "What brought you here?" or "Why are you seeking Case Management, ARMHS, Psychotherapy this time?"

Likely the person will describe a problem they are having or a crisis they are facing. Or, the individual might phrase the answer in the negative: "I don't want to feel so depressed anymore." Regardless how the individual answers this question it might be that the answer is that person's first, and most important goal.

What we're saying here is that goal-setting is not a formal process where you take out your pen and notebook, or your laptop or tablet and ask, "What are your treatment goals?" or "What is your recovery vision? Rather, it is a natural process of getting to know people and what changes they want in their life.

Treatment Goal, and Recovery Vision are our lingo. We can introduce those terms during the planning process, which is also a process of education, but we begin with natural conversation, with sincere interest in the person and his or her needs, not our need to fill in and label the boxes correctly in the medical record.

But let's explore terms in Goal-Setting for a moment. We generally encourage you to record three types of goals in a person's record, phrased in positive terms. These are:

Treatment Goals: the needs we respond to directly in the treatment plan. Treatment Objectives are linked to Treatment Goals.

Personal Goals: other goals a person might have that are not directly treated with services, but that give us insight into the bigger picture of the person and what they want out of life. Recording these is optional, up to each person.

Check This Out:

Watch this inspirational and entertaining clip from a talk by Dr. Pat Deegan, advocate and speaker on mental health. In it, she describes the Recovery Vision she discovered for herself when she was diagnosed with schizophrenia.

Recovery Vision: The Recovery Vision is the big picture. It paints a picture of how an individual would like his or her life to be different than it is now, where mental health symptoms have prevented them from living the life they desire. Treatment Objectives might also be linked to a person's Recovery Vision. It may be that and individual's Recovery Vision is clear from the outset. Rather, that might emerge over time as we work with them.

Set Positive Goals

Goal-setting with the people we serve is not a one-time thing. It is a fluid, ongoing process where we continue to listen, reflect, clarify and find ways to articulate, in positive terms, a person's goals, hopes and dreams. It is also, at times, a process of hearing and understanding what someone does not want, and then, with them, describing the positive alternative. Here are some examples of that:

Exercise

Write two or three goals for yourself now using the following steps:

1. What are two or three things you would like to be different in your life?
2. Are the statements you wrote phrased positively? If not, rephrase them in the positive now.
3. Describe each goal in more detail, if you wish, to help others understand it.
4. What strengths and resources do you have that will help you achieve these goals?
5. What are the barriers to you achieving each goal?
6. What help do you need from others to achieve them?

Writing Goals

What we require of goals is simply that they are the person's goals, phrased in their terms (perhaps with assistance from you) and that they are stated in the positive. Don't worry if the goals a person identifies may not seem as achievable as you might like, or as objectively measurable. Getting to measuring progress toward goals comes in the Treatment Objectives, and specifically in what we call Desired Outcome statements within those objectives. Read on for more about that.

Objectives

Treatment Objectives are the core of the treatment/service plan at Accend. They are tied to treatment goals, and to domains of functioning (e.g. Symptom Management, Interpersonal Skills, etc.) and describe the treatment services we will provide, and how we will measure success.

The core elements of Treatment Objectives are:

• The Goal with which is associated;
• The Domain being treated;
• Rationale (Why are we providing treatment or services in this domain? For some services, ARMHS and Case Management, for example, the rationale comes from the functional assessment.);
• Desired Outcome statements;
• Methods (how will services/treatment in this objective be delivered?);
• Frequency and duration of the services to be provided.

For some service types, there are other elements in treatment objectives, such as treatment resources that will be used, but the core elements above exist in all objectives.

Outcomes

The most important element in the Treatment objective is the Desired Outcome Statements, because this how we will measure the success of the services in a plan. Desired Outcome statements are tangible, measurable steps toward goals. They might describe one-time accomplishments, changes in behavior, or new healthy habits. Learning to write measurable outcome statements is your most important task as a case manager or practitioner.

High quality Outcome Statements:

Are Small Steps Toward the Goal

Are Objectively Measurable or Reliably Reportable

Describe a tangible, observable accomplishment or behavior, or an achievement that a person receiving services can reliably report. This can be challenging, but a simple exercise to test whether or not an outcome is tangible and observable is...

The Two Person Test

Consider this statement: "I will use caution when crossing the street."

Now imagine that person using caution while crossing the street. Describe what you see. Now ask a coworker to describe what he or she sees. Does it match? It may or may not. You both might describe someone going to the crosswalk rather than crossing in the middle of the block, perhaps waiting for the walk signal, perhaps stopping, perhaps looking both ways before crossing.

This may be a simplistic example, but it gets at this point: which of these behaviors are you looking for to improve street safety? Measure that one behavior. Perhaps you want to see all of them. That is fine too, but we also want to avoid a statement that measures more than one thing (more about that next.)

Measure Only One Thing

Double-barreled outcome statements are a common trap and easily detected by the presence of the word and within the statement.

For example, a person wanting to improve his or her health may commit to participating in better preventative care. An accomplishment outcome statement might say, "I will make and attend an appointment for an annual physical by June 30th." This is a double-barreled statement because it includes making and attending the appointment. Avoid this by measuring the ultimate outcome by simply writing "I will attend..."

Let's revisit the street safety example above. There are three for four steps that might be included in the definition of using caution: using the crosswalk, waiting for the signal or stopping, and looking both ways. You want to see all of these steps. A single-barreled statement could say, "I will follow all four rules for safely crossing the street."

When you're measuring a behavior that includes following all of several steps or rules like this, you will list the steps or rules in the methods. It is also acceptable to break down multiple steps into separate outcomes if needed, because you want to measure success in each.

Get To the Ultimate

Using the Objective Builder

Progress Review

Progress review is an integral part of the treatment process. It provides you, with the people you serve, to:

• Celebrate success
• Check in on
• satisfaction with services
• whether or not a person's needs, priorities, goals and objectives remain the same or have changed
• engagement and satisfaction with other services to which the person has been referred or is receiving
• Identify new problems, needs, or barriers to success
• Change course in services or treatment if needed

That being said, Progress Review should by default be done with the people you serve (and/or a child's parents or caregivers, in person, and as a natural and expected part of treatment/services, not an interruption of them. Only when a person has disengaged from should Progress Review be done apart from the person and then it should be part of case review with your Team or Clinical Lead.

You will do two types of Progress Review, as follows.

Mid-Plan Reviews

Mid-plan progress reviews are required every two months following the start date of the Service Plan.

These mid=plan reviews are a brief look back on what has occurred since the start of the plan. In the Progress Review you will see progress ratings for each of the objectives in the treatment/service plan, and you will comment on these ratings in a narrative.

Your narrative should be a concise summary of your progress notes from the services since the previous review, including what you and the person you serve have accomplished, what you are still working on, the thoughts and feelings of the person you serve about how things are going, and any changes or course corrections you have mutually agreed are necessary to move forward.

It may be, during this lookback, that you discover that the plan is not working, or that progress on objectives is flat or negative. This may be because:

• The plan that you and the person you serve had written does not really his or her their needs
• The person's needs and priorities, goals or objectives have changed
• Other barriers to progress, needs or problems have arisen that need to be addressed before progress can continue
• The person is making progress, but the plan is not measuring it

When you make these discoveries during the mid-plan progress reviews, it may be a sign that you need to update the plan early. This is perfectly acceptable, in fact it is a best and required practice to do so if you and the person you serve identify that a plan, regardless of how carefully-crafted, is not meeting the person's needs.

Mid-plan reviews help us comply with the requirements of Mn Statute 245I Subdivision 5, for services governed by this statute. 245I requires that "Treatment supervision of mental health practitioners and clinical trainees required by section 245I.06 must include case reviews as described in this paragraph. Every two months, a mental health professional must complete a case review of each client assigned to the mental health professional when the client is receiving clinical services from a mental health practitioner or clinical trainee." However we require them for all services as a standard best practice.

Plan Update or Discharge

Prior to updating a plan, you will conduct a plan update review. This includes updates to Functional or other assessments required for the service, and, annually, a Diagnostic Assessment.

The Plan Update Review is more comprehensive, includes recommendations by the Clinical Supervisor of the service, and is required prior to building a new plan.

You will also complete a Progress Review as part of discharge from services, whether the discharge is planned or as a result of disengagement.

Steps in Progress Review

Steps in Progress Review and the types of reviews and services are as follows:

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