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Principles of Person-Centered Assessment and Planning

Overview

This section of the training guide is under construction. Please visit again soon to see our progress.

Foundational Principles

What You Will Learn

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 charactarized 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 "ampllifying the well." While ARMHS eligibility is defined by deficits, treatment in ARMHS should be charactarized by buillding on an individual's strengths, current resources, and resourcefulness.

Person-Centered

Person-centered means assessment is conducted with people, not at a desk apart from them.

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 illness.

Models of care have changed over time. A traditional/historical model of care focused on the diagnosis, disease, and deficits, where as a person centered model of care focuses on the client’s abilities, preferences, and individual needs. The following table compares the focus of various aspects of the traditional/historical model of care and the person centered model of care. The comparison shows that a person centered model of care recognizes and empowers the individual in treatment.

Historical/Traditional Person-Centered
Deficit-based model of care, using standardized assessments and treatments Strength-based model of care. Disability is only one of the characteristics considered in model of care.
Care is focused on fixing problems. Care is focused on supporting them in learning skills.
Professionals make decisions about treatment The person served makes decisions about care.
Control: professional judgement and decision making Partnership/shared decision making
Goals decided for the client Driven by the individual's goals
Stabilization is the desired result Quality of life is the desired result
Fit person and treatment plan into the program parameters Individualized


Language

Consider these examples of strengths-based thinking in the words you use (and the way you think):

Denial  -  Pre-contemplation
Resistent  -  Reluctant
Refused  -  Declined
Dirty UA  -  Positive UA
Manipulates  -  Gets needs met
Demanded  -  Asked

Recovery-Oriented

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.

When writing a Recovery-Oriented Plan do the following:


Using One Page Profiles

What You Will Learn

A One Page Profile leads to positive change for a person by listing what really matters for that person. In a single page, a One Page Profile embodies significant information about a person. The three headings in a One Page Profile are: what people appreciate about me, what’s important to me and how best to support me. Answering these questions in one page provides a foundation for relationship building, ease in transitioning from service to service, and reflect changing circumstances when updatingn the profile. The following video reflects the outcome of using a One Page Profile.



> Tap here for a printable One-Page Profile worksheet.

Goals

What You Will Learn

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.

Recovery Vision, and Treatment Goals 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:

Recovery Vision: The Recovery Vision is the big picture and the ultimate Treatment Goal. 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. 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.

Treatment Goals: Break down the recovery vision as needed in to more detailed or focused areas of need.

Treatment Objectives must be linked to either the Recovery Vision or 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.

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:

I don't want to be so depressed anymore. I want to enjoy life.
I don't want to lose my children. Be a better parent.
I don't want to be so lonely anymore. Meet people and make friends.
I want to stop hearing voices. I want to learn how to cope when I am hearing voices.
I want to lose weight. Get healthy/get in better shape.

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 Measurable 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 objectively measurable. We can deal with that with the other elements of the goals tool in TabsTM as follows:

Goal: It is important to use the individual’s (or parent’s) own words here, but coach them to phrase the goal in positive terms. If as stated, the goal does not appear objectively measurable, consider using the Detailed (optional) description of the goal or How will progress on the goal be measured to arrive at measurability.
Goal Identified on (date): This just identifies the date on which you helped them identify this goal
Type of Goal: Select from Health and Wellness, Treatment Goal, Recovery Vision, or Personal Goal. Health and Wellnss and Treatment Goals are what we will use for Treatment Objectives.
Services with which this goal is associated: From among the services the individual may receive, select all of the services that may be used to help the individual achieve the goal.
When would you like to achieve this goal: This is a target date and for Treatment Goals, consider goals that can be achieved in 3 months to 3 years.
Detailed (optional) description of the goal: For a goal statement that is not objectively measurable, consider using this section to identify details that are tangible, achievable and measurable.
Strengths and resources that will help in achieving this goal: It is important to identify current strengths and resources that a person has that we can build on to achieve goals
Barriers to the goal (including mental health symptoms: These are the barriers that include symptoms, impaired functioning, health, lack of resources or personal support systems that stand in the way or may impede progress toward the goal.
Describe what/how services will support the client in pursuing this goal: Without too much detail, describe services at Accend or services needed from other providers (Health, Human Services, etc.) that the individual will need to overcome barriers to goal achievement.
How will progress on the goal be measured: This is another opportunity to make the goal measurable. Do not describe when the goal will be measured (in monthly progress reviews) but rather how. What benchmarks, personal rating scales (satisfaction, impact of symptoms, etc.) that the individual will use to identify progress toward the goal.

Objectives

What You Will Learn

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:

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 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.)

The Dead Man's Test

Can a dead man do what you've described? Avoid outcome statements that describe stopping a behavior or the absence of a behavior. A dead man can not do something. Instead, when writing statements about an undesirable behavior or habit a person wants to change, describe the alternative, positive behavior that the person will exhibit that replaces the undesirable.

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

Outcome statements measure smaller, tangible accomplishments and changes in behavior that will help a person move closer to the long-term 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...

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

While measuring the small steps, don't lose sight of the ultimate end goal. Outcomes should progress toward the goal and the final statement should describe an outcome that looks like mission accomplished!

Using the Objective Builder

Statement Type Use For Example
Frequency & Duration Developing a new healthy habit/routine Tess will exercise for 30 minutes 4 times per week for a month by 9/30/2018.
Cumulative or Scaled Counting a total number of small accomplishments or tasks completed.

Reaching and maintaining (or averaging) a desired rating on a scale (satisfaction, confidence, etc.).		 Tess will lose 10 pounds by 12/31/2018.

Tess will average a 4 out of 5 on her customized "How Healthy Do I Feel?" scale.
Percent of Opportunities Measuring successes as a target percent of trials. Tess will follow her daily diet plan 80% of days each month by 9/30/2018.
Duration Behavior sustained over a period of time. Tess will walk without stopping for 30 minute(s) 3 out of every 4 trials for 1 week by 9/30/2018.
Conditions and Behavior Change Trying to replace a current behavior that occurs in certain circumstances or conditions and that is not working well. Where now Tess keeps eating/grazing after dinner when she is stressed, instead she will take a walk after dinner 5/7 opportunities by 8/31/2018.
New Accomplishment A one-time accomplishment. Tess will buy a new dress for Christmas Mass by 12/20/18.

Adult Standardized Outcomes

For information about using standardized outcomes for adtuls, read the Adult Standardized Outcomes Guide in Best Practices.

Outcome Statements Exercise



And The Nominees Are...

Using Treatment Resources

Some services require the use of authorized Treatment Resources. We maintain a Treatment Resources Library in Tabs with vetted resources. Please use only authorized resources. Depending on the service your are providing a resource may populate into your progress note, a list of skills you can identify having worked on during a session.

You can search the library by resource name, skill, or domain as shown in the image here.

When using treatment resources, please:

What You Will Learn

Using the Adult Intake Adult Intake Assessment and Plan and Adult Re-Engagement Assessment and Plan

These two plan types are combined assessments and plans for quickly engaging new referrals or re-engaging clients who have disengaged and re-approach us for help when assessment and plans have expired. They combine required assessments for:

For new referrals, use the: Adult Intake Assessment and Plan.

For re-engaging clients use the: Adult Re-Engagement Assessment and Plan.

For both, when building a plan for ARMHS or Case Management, and adding new objectives, you will need to use the objective types:

These objective types allow you to write a manual treatment rational for the objective (it will not populate automatically from this combined assessment and plan). For all other services, typical objective types will work as they currently use manual rationales.

Record the FA/HWA Separately

To use either combined assessment and plan, you must first complete the combined document, then record it using the Record of FA/HWA from Combined Assessment and Plan found in assessments.

For further instruction, see the Adult Functional, HWA, Level of Care, and Status Asssesssment section here.

Expiration

The Engagement and Re-Engagement Assessment and Plan is intended to remove barriers to enagement and is set by business rules to expire at 90 days, at which time a full Functional Assessment and Integrated Plan should be completed and approved.

Progress Review

Progress Review is an integral part of the treatment process, and should be completed with the recipient or with children's parents or guardians. It provides you, with the people you serve, to:

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 (Every Two Months)

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:

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.

Resources

Check back from time to time. This resource list may grow.

DSM-5-TR Assessment Measures (See Level 2 Adult)

DSM-5-TR Cross-Cuting Assessment Measures Training 2023

Feedback or Questions about this Chapter

This guide is a living document. We want to improve it with your help. Do you have questions? Found a typo? Find yourself wanting more information? Please send us your thoughts about anything in this chapter by tapping on the link below.

Questions, Feedback & Suggestions

Updates to this Chapter


March 14, 2023: Language added to the section on Using the Adult Intake Adult Intake Assessment and Plan and Adult Re-Engagement Assessment and Plan to clarify that these plans are set to expire at 90 days from approval.


July 17, 2023: Progress Reviews required every 60 days for all services.


November 2, 2023: Treatment Resources added (DSM-5 Crosscutting Measures).