Welcome and Introductions Presented by MHSACM DMH 1

Welcome and Introductions Presented by MHSACM & DMH 1

Assessments Group Name Affiliation Sherry Davis, Lead Bay Cove Human Services Susan Abbott Vinfen Steve Chisholm CAB Health & Recovery Dave Selden SDT Co-Facilitator North Suffolk Mental Health Porter May Advocates Presented by MHSACM & DMH 2

Individualized Action Plan Group Name Affiliation Stephanie Sladen, Lead Health & Education Services Rita Barrette Department of Mental Health Jan Feingold High Point Treatment Center Jordan Oshlag SDT Co-Facilitator Community Healthlink Michael Stuart Spectrum Health Systems Presented by MHSACM & DMH 3

Progress Note Group Name Affiliation Nancy Carlucci, Lead Network Health Dallas Gulley Riverside Community Care Joe Passeneau MBHP Anne Priestley Wayside Youth & Family Presented by MHSACM & DMH 4

Thank you! • • DMH DPH/BSAS MHSACM MBHP CHD Presenters Countless volunteers Presented by MHSACM & DMH 5

Morning Agenda The MSDP – Goals, Origins, Where we are today, The Golden Thread Assessment Group of MSDP Processes - Form by Form, Section by Section Review Break IAP Group of MSDP Processes - Form by Form, Section by Section Review with an Application Work Session Lunch Presented by MHSACM & DMH 6

Terms MSDP Massachusetts Standardized Documentation Project EMR/EHR Electronic Medical Record / Electronic Health Record QMC Quality Management Team SDT Standardized Documentation Team CRT Compliance Review Team CFAAC Consumers, Families, and Advocates Advisory Committee: Membership on CFAAC Presented by MHSACM & DMH 7

More terms CBFS Community Based Flexible Supports Recovery Orientated Person Centered LPHA Licensed Practitioner of the Healing Arts RAC Recovery Audit Contractor Program OIG Office of the Inspector General Presented by MHSACM & DMH 8

Paradigm Shift OLD NEW Comprehensive Assessment CA - Comprehensive Assessment Program Specific Treatment Plan IAP – Individualized Action Plan Patient, Client, Consumer Person Served Presented by MHSACM & DMH 9

How did we get here Presented by MHSACM & DMH 10

Quality of Care Benefits – Promotes consistent assessment, planning & service documentation – Person-Centered and Strengths focus – Recovery/Resiliency focus – Promotes Information Sharing • Promotes effective collaboration with other providers & shared terminology for use by different disciplines – Less room for error; Decision support – Enhances measurement & outcomes focus Presented by MHSACM & DMH 11

Benefits of Participating – Free training and forms – Compliant with a wide variety of regulatory and payer requirements • Some protection against federal audits – Saves time and money • Reduces redundancy in collecting information • Concurrent documentation possible – Standardized revisions and updates in future Presented by MHSACM & DMH 12

MSDP Forms and Manual Website • MSDP 2009 version of the paper forms, e-forms and manuals can be downloaded by program type at the website: • http: //www. mtmservices. org/MSDP/2009 forms. html • MSDP UPDATE Website: http: //www. mtmservices. org/MSDP-Update. html • Technical Assistance will be provided by the MSDP Leadership Team. Email at MSDPHelp@Earthlink. net Presented by MHSACM & DMH 13

Documentation Linkage “The Golden Thread” Assessment Data Diagnoses - Assessed Needs – Service Recommendations Individualized Action Plan Goals Individualized Action Plan Objectives Rehabilitative Services and Interventions Progress Notes Presented by MHSACM & DMH 14

Medical Necessity “The type, intensity and duration of an intervention as provided by a qualified practitioner and ordered by a qualified practitioner in the current action plan is needed to prevent worsening and/or produce improvement of symptoms, behaviors and/or functioning level related to an approved diagnosis and assessed needs” Presented by MHSACM & DMH 15

Medical Necessity – Auditor View Provided Service • Appropriately Qualified Practitioner • Clinically Appropriate and Allowed Services • At appropriate Intensity and Duration As Prescribed in • Individualized Action Plan Designed to • To improve functioning, symptoms and/or behaviors or prevent their worsening Based on • An Approved Diagnosis and Assessed Needs Presented by MHSACM & DMH 16

CBFS STANDARDS A. Screening & Enrollment B. Assessment C. Individual Action Plan (IAP) D. Notes E. Client Records Presented by MHSACM & DMH 17

CBFS STANDARDS: Screening and Enrollment • • Timelines for completion Cultural and linguistic considerations Documentation Purpose LPHA responsibility Critical Needs Plan Client orientation Presented by MHSACM & DMH 18

CBFS STANDARDS: Assessment • • • Timelines for completion Cultural and linguistic considerations Strength based and person centered Includes additional assessments as indicated The Golden Thread LPHA responsibility Signatures Who receives the completed assessment Reviews and modifications Presented by MHSACM & DMH 19

Adult Comprehensive Assessment (CA) • Standard format to assess mental health, substance use and functional needs • Summary of assessed needs serves as the basis of Individualized Action Plan Goals and Objectives • Completed by the LPHA after interviewing the person served, face to face Presented by MHSACM & DMH 20

Adult Comprehensive Assessment (CA) Personal Information • Captures essential demographic, contact and insurance/billing information Presented by MHSACM & DMH 21

Adult Comprehensive Assessment (CA) • Living Situation – Only need to complete one check off box • Family and Social Support History • Legal, Education, Employment, Military, etc. – Complete Addenda if additional information is needed; depends on person’s needs • Substance Use – Screening tool needed to determine if there is a substance use problem Presented by MHSACM & DMH 22

Adult Comprehensive Assessment (CA) • Health Summary – If Physical Health Assessment has been completed, do not need to complete again here • Advanced Directives – Follow your agency’s protocols with regard to Advanced Directives • Trauma History – If not addressed during initial comprehensive assessment, Trauma Addendum is available for completion in future sessions Presented by MHSACM & DMH 23

Adult Comprehensive Assessment (CA) • Strengths/Abilities/Resiliency – Key component of the assessment – Important shift in assessment process – Strengths-based assessments increasingly more common; used to generate goals and objectives • Interpretive Summary – Summary - not meant to repeat data already gathered – Answers the question: How does the data gathered in the assessment fit together and how will it be used to create an action plan? Presented by MHSACM & DMH 24

Adult Comprehensive Assessment (CA) • Was outcomes tool used? – CBFS providers may choose to use an outcomes tool – If outcomes tool is used important to include findings when completing CA • Inclusion of Person Served – Important to include person/family response to recommendations – Give person option to read and sign assessment Presented by MHSACM & DMH 25

Adult Comprehensive Assessment (CA) Addenda • Addenda: Education, Employment, Legal, Military, Trauma, Substance Use • Addenda created to shorten the length of the CA • Allows for capture of information relevant to each person served Presented by MHSACM & DMH 26

Addendum Example Presented by MHSACM & DMH 27

How to Access CA Addenda Presented by MHSACM & DMH 28

Assessed Needs Checklist • Functionally oriented • Captures categories other than functioning as well (Addictive Behaviors, Family and Social Support, etc. ) • Allows for use of Agency specific functional assessment • Combination of clinical and rehab oriented needs Presented by MHSACM & DMH 29

Prioritized Assessed Needs Presented by MHSACM & DMH 30

Adult Comprehensive Assessment (CA) Update • Person may experience other issues/symptoms indicating an additional mental health and/or substance use concern that needs to be addressed by the program • To maintain Golden Thread: CA Update form must be completed to document need as an “assessed need” and to support Goals/Objectives in the IAP Presented by MHSACM & DMH 31

Adult Comprehensive Assessment (CA) Update • Saves time and effort • Provides an ongoing cumulative history of assessed needs of the person served • Completed by LPHA after interviewing the person served, face -to-face • Placed in date order on top of the CA in the chart to provide the appropriate linkage to new services if information provided indicates new services are needed: maintains the ‘Golden Thread’ Presented by MHSACM & DMH 32

Form Components • Record the reason for the update • Enter the date of the last Comprehensive Assessment in the chart • Adult Comprehensive Assessment Sections for Update • Update Narrative • Signature/Credentials Presented by MHSACM & DMH 33

Diagnosis • Official Diagnosis for the person is “Housed” in the CA or in subsequent CA Updates • If there is a change to the existing Diagnosis or Diagnosis added it must be recorded in the CA Update • If there is no change to the diagnosis, indicate that by checking the appropriate box Presented by MHSACM & DMH 34

Treatment Recommendations/ Assessed Needs • Document any new treatment recommendations or assessed needs • Any new recommendations/needs should be considered the basis for subsequent treatment goals and/or objectives Presented by MHSACM & DMH 35

CA Update Process Linked to Treatment Recommendations • If the Treatment Recommendations/Assessed Needs are adequately addressed by the Treatment Recommendations/Assessed Needs as identified in the original Diagnostic Assessment or earlier CA Updates, then check the box for “No Additional Recommendations Clinically Indicated” in the appropriate section of the CA Update • Determine if existing Goal(s) and Objective(s) address the newly identified recommendations/needs • If yes, use the Progress Note to identify the appropriate Goal and Objective and provide the interventions ordered • If NO…. Presented by MHSACM & DMH 36

CA Update Process Linked to IAP Revision • If existing Goals, Objectives, Interventions, Services, frequency and provider types will NOT meet the client’s newly identified Treatment Recommendations/Assessed Needs, then link the newly assessed needs from the CA Update to an IAP Revision by checking “Change In IAP Required”. Update the IAP accordingly. Presented by MHSACM & DMH 37

Risk Assessment • Optional form • Please check your agency’s risk assessment procedures! • Used to assess risk of harm to self or others as part of a comprehensive assessment or when assessing a person in crisis • Gathers data on relevant risk issues and severity Presented by MHSACM & DMH 38

Tobacco Assessment • Optional form • Please check your agency’s tobacco assessment procedures! • Assesses current/past tobacco use and readiness to change Presented by MHSACM & DMH 39

HIV Risk Assessment • Optional form • Please check your agency’s HIV risk assessment procedures! • Assesses current/past risk behaviors as well as willingness for testing and treatment Presented by MHSACM & DMH 40

Physical Health Assessment Optional form Please check your agency’s procedures! Required annually and as needed Assess current/past medical issues of the person served that may impact current functioning • Gathers test results that may be pertinent for functioning in the future • • Presented by MHSACM & DMH 41

BREAK Presented by MHSACM & DMH 42

CBFS STANDARDS: Individualized Action Plan (IAP) • Timelines for completion • Cultural and linguistic considerations • Meeting schedules • Participation • Strength based and person centered • LPHA responsibility • Signatures • Who receives the completed IAP • DMH involvement • Additional assessments • Reviews and modifications • The Golden Thread Presented by MHSACM & DMH 43

IAP Group Documentation Processes/Forms • Individualized Action Plan (IAP): – Expanded – Condensed – Short w/ Multiple Goals • Transfer/Discharge Summary and Plan • IAP Review/Revision Presented by MHSACM & DMH 44

IAP • To promote principles of recovery, IAP serves as what is now known as a treatment plan • Name reflects the recovery concept of shared decision making • Used to document collaboratively identified goals, objectives, and therapeutic interventions Presented by MHSACM & DMH 45

IAP • Links needs identified during the assessment to rehabilitative interventions • Serves as a tool to collaboratively build an IAP which reflects both medical necessity and the desired outcomes of the person served in his or her own words • Design encourages collaboration amongst programs and across agencies Presented by MHSACM & DMH 46

IAP To supporting a recovery focus: • transition and discharge planning is advised from the earliest possible point in treatment • a section is provided on the form to assist in this process. Presented by MHSACM & DMH 47

IAP • Multiple versions are available – Expanded: one page per goal, ample space for writing, page for objectives, which correspond with the goal – Condensed: space to document a goal with two objectives on one page – Short with Multiple Goals: multiple condensed goal pages within one document Presented by MHSACM & DMH 48

IAP Review/Revision • Designed to document information from: – ongoing review(s) – revision(s) of goals and objectives, and/or – periodic rewrites • Minimizes duplication • Documents information to demonstrate evidence and/or rationale for revision Presented by MHSACM & DMH 49

IAP Review/Revision • Used to update or modify the IAP: – Revisions: to add a new goal; change goals, objectives or interventions; or change the frequency or duration of services; – Reviews: to record the progress of the person served and – Rewrites: annually, after three interim revisions, or per agency protocol, a “rewrite” of the actual IAP is warranted. This will facilitate the identification and tracking of treatment goals/objectives and progress made. Presented by MHSACM & DMH 50

IAP Review/Revision • Revision and Review: – Use both pages of the IAP Review/Revision form – Additional IAP goal and/or objective sheets should be added as necessary – If a new goal and/or objectives sheets are completed, they are attached to the IAP Review/Revision form Presented by MHSACM & DMH 51

IAP Review/Revision • Rewrite: – Use page 1 of the IAP Review/Revision – Complete a new IAP – Attach new IAP to the IAP Review/Revision form Presented by MHSACM & DMH 52

IAP Review/Revision • Anytime a new goal and/or objective is added during the Review/Revision: – Review the most recent Comprehensive Assessment – Is the new goal and/or objective supported in the Comprehensive Assessment? – If NO, a Comprehensive Assessment Update form must be completed • Remember the ‘Golden Thread’ Presented by MHSACM & DMH 53

Transfer/Discharge Summary and Plan • Use at the time of transition within CBFS: – To or from a CBFS group living environment – To or from a CBFS individual living situation • Use at the time of discharge from CBFS • Summarize treatment, reasons for transition/discharge, and plans for referral to assist the person in following through on aftercare recommendations. Presented by MHSACM & DMH 54

Individualized Action Plan Group Processes/Forms Application Exercise Presented by MHSACM & DMH 55

LUNCH Presented by MHSACM & DMH 56

Afternoon Agenda Progress Note Group of MSDP Processes - Form by Form, Section by Section Review Break Interplay between forms: New Goals, New Information, Updates Implementation Strategies Questions and Discussion Presented by MHSACM & DMH 57

CBFS STANDARDS: Progress Notes • Timelines for completion • The Golden Thread • Other documentation Presented by MHSACM & DMH 58

KEY ELEMENTS • Therapeutic Interventions Provided • Client’s Response to therapeutic interventions, progress and functioning • Interventions Linked to IAP interventions • New Issues Presented by MHSACM & DMH 59

KEY ELEMENTS Therapeutic Interventions and Person’s Response to interventions Presented by MHSACM & DMH 60

KEY ELEMENTS Linkage to specific Goal(s)/Objective(s) in IAP Presented by MHSACM & DMH 61

KEY ELEMENT - “New issues” Four Options: 1. “None Reported” 2. If resolved during the session, document in the “Person’s Response Section” 3. If already part of the Goals and Objectives, document the progress in the “Person’s Response Section” OR… Presented by MHSACM & DMH 62

KEY ELEMENT - “New issues” 4. When a new issue with a therapeutic need is not addressed in the IAP: • Check “CA Update Required” • Document using the Comprehensive Assessment Update as instructed in the manual. • May require an IAP Review/Revision to document new goal, objective, therapeutic intervention or service Presented by MHSACM & DMH 63

Nursing (Long or Short) • Optional Form: Please check your agency’s procedures! • To be completed by a LPN, RN, BSN, or MSN • Use either long or short version depending on amount of space needed Presented by MHSACM & DMH 64

Consultation/Collateral Contact • Optional Form: Please check your agency’s procedures! • Use for face-to-face/telephonic consultation/collateral contacts. • Identifies next action steps and responsible party. Presented by MHSACM & DMH 65

SHIFT/DAILY • Optional Form: Please check your agency’s procedures! • Document interventions that are not part of the IAP. Goals and Objectives – N/A Presented by MHSACM & DMH 66

Healthcare Provider Orders • Optional Use: Please check your agency’s procedures! • Serves as ongoing communication tool amongst providers. • Ensures thorough and current medication list. 2. Self Medication Training Plan Presented by MHSACM & DMH 67

CBFS STANDARDS: Client Records • Consolidated record • Contents of record • Confidentiality Presented by MHSACM & DMH 68

BREAK Presented by MHSACM & DMH 69

Interplay between forms Presented by MHSACM & DMH 70

Interplay between forms CA New Assessed Need IAP New Goal/Objective CBFS Progress Note New Information/Issue/Goal/Objective Presented by MHSACM & DMH 71

CBFS IMPLEMENTATION Presented by MHSACM & DMH 72

Implementation of New Forms We acknowledge. . . Training is needed to adapt Initially it can take more time to use May require change to internal processes There is a possible lack of understanding of The Golden Thread • CA Update and IAP Review/Revision processes may not be understood • Process focuses on the integration of services and documentation • • Presented by MHSACM & DMH 73

Existing Record Keeping Systems We acknowledge. . . • It costs to make changes to current systems • There are investments in current systems • There may not be enough space to write on forms • There are no lines in text boxes • Forms can’t be changed Presented by MHSACM & DMH 74

Incorporating a Recovery Culture We acknowledge. . . • We are shifting from a culture of doing for clients to a culture of empowering clients • There is a need for more training on recovery and resiliency. • There is a need for more training on Medicaid Rehab Option Presented by MHSACM & DMH 75

Staff Training and Supervision We acknowledge. . . • Staff will go through stages from denial to acceptance during implementation of the forms • There may be a need to provide more frequent and different types of supervision during implementation • There is a need, initially, for closer monitoring of the quality of documentation Presented by MHSACM & DMH 76

Focus Areas to Assist in the Implementation of MSDP Forms 1. 2. 3. 4. 5. 6. 7. Be proactive about training and re-training needs Provide coaching sessions on documentation Develop and provide to staff a written implementation plan including training, support and a change management strategy Develop post implementation monitoring tied to CQI efforts Include staff in problem solving the implementation Try the MSDP e-forms. Try each form at least 7 times and then keep track of issues, problems, suggestions for improvement. Presented by MHSACM & DMH 77

Transition All Clients enrolled as of July 1, 2009 • 72 hour screening is not required • For clients enrolled with new provider an ‘evaluation’ of immediate needs should be completed at first contact • By August 1, 2009 all clients are provided with an orientation to the provider and its CBFS services according to CBFS standards. Presented by MHSACM & DMH 78

Transition to the MSDP Forms Group 1: Residential and RTC clients Group 1 Criteria: Clients do not change provider • Current DON • Maintain current PSTP anniversary date • Implement new CA and IAP forms at time of annual review • Begin use of progress notes as of July 1 • Client level rehab billing based on current PSTP Presented by MHSACM & DMH 79

Transition to the MSDP Forms Group 2: Residential and RTC clients Group 2 Criteria: Clients change provider • Current DON • Maintain current PSTP anniversary date • Implement new CA and IAP forms at time of annual review • Begin use of progress notes as of July 1 • Client level rehab billing based on current PSTP Presented by MHSACM & DMH 80

Transition to the MSDP Forms Group 3: CRS clients Group 3 Criteria: All Clients who were previously enrolled in CRS regardless of whether or not provider is changing • Prioritize clients for implementation of new CA and IAP forms within first 6 months • Begin to use progress notes as of July 1 • Client level rehab billing will occur when new forms have been completed Presented by MHSACM & DMH 81

Transition to the MSDP Forms Group 4: Clients newly enrolled after 7/1/09 Group 4 Criteria: All Clients regardless of past service history who are newly enrolled in CBFS • MSDP Forms must be used from the onset • CBFS Standards must be followed from onset • Client level rehab billing will occur when new forms have been implemented Presented by MHSACM & DMH 82

Technical Assistance and Support DMH will: • Work with each CBFS provider to develop a reasonable implementation schedule • Be available to review documentation and provide feedback • Be available to provide additional training and technical assistance as needed Presented by MHSACM & DMH 83

Resources • • How to start Integration Planning Help: – MSDPHelp@Earthlink. net Presented by MHSACM & DMH 84

Questions and Discussion Presented by MHSACM & DMH 85