Mental Health and Wellness Program

MENTAL HEALTH AND WELLNESS PROGRAM

Meeting the Policy and Requirement Handbook (PRH) Requirements for

Documentation

Valerie Cherry, PhD

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Mental Health and Wellness Program Chapter 6.10, R3

Mental Health and Wellness

ProgramChapter 6.10, R3

General Emphasis

(a)

Assessment(b)

Promotion, Prevention,

and Education

(c)

Treatment(d)

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Mental Health and Wellness Program

(a) General EmphasisEarly identification and diagnosisBasic mental health careMental health promotion, prevention and educationEmployee assistance program approach

Short-term counseling with focus on employability Referral to center support groups Crisis intervention

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Mental Health and Wellness ProgramDocumentation

(b) Assessment Social Intake Form

Most recent was released via Information Notice 12-31- November 16, 2012

Bottom date - October 2012 Review within 1 week Signed by CMHC Completed Copy or Original in SHR

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(b) Assessment Con’t Assessments and Recommendations for

Referred Students What should the Intake include?

Reason for Referral Presenting Problem Mental Health History Chemical Health History Mental Status Exam Barriers to Employability and Strengths DSM Diagnosis, if applicable Education and Recommendations

Referral to Reasonable Accommodation Committee

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(b) Assessment Con’t Intake Assessments should be placed in MH

section of SHR Progress Note Mental Health Intake Forms (DRG) Provide student with Mental Health Chronic Care

Management Plan (MHCCMP) Student Fact Sheets and note in SHR

Job Corps Information Notice 13-51 “Updated Chronic Care Management Plans”, dated April 10, 2014 Flow Sheets for recording periodic monitoring

visits for students with Schizophrenia, Bipolar Mood Disorder, and Depression

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(b) Assessment Con’t MSWR or Medical Separations

Progress Note in MH section What should be included?

Clinical justification for the separation due to health needs beyond what can be managed on center.

Sometimes you may be asked for a recommendation on mode of transportation and if an escort is needed.

Resource: Medical Transfer, Separation, and Referral; Management of Student Injury and Death Under FECA/OWCP TAG

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(c) Mental Health Promotion and Education 1-hour CPP Presentation

Curriculum Standing day of the week for new inputs

CDP and CTP Presentations Curriculum Maintain a folder/binder, or computer file with days

and topics

Annual Center Wide Activity Maintain a folder/binder or computer file with

information

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(c) Mental Health Promotion and Education Con’t Clinical Consultation with CD (monthly),

Mgt. Staff, and HWM Minutes

Coordination with other departments Keep file on specific trainings for Counselors

and/or Residential Advisors. Include SGA, HEALs and other center

departments with center wide activities and document in your file their participation in developing the activity.

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(d) Treatment Short term with employability focus

Document on progress note in MH section of the SHR

How do we document employability focus in a note?

Sample Progress Notes in DRG MHCCMP Student Fact Sheet

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Employability Focus

Student was referred by counselor for acting out behavior in the classroom. Student has history of anxiety and expressed feeling stressed out on center and difficulty with peers. Refer for medication evaluation and return in 1 week.

Student was referred by counselor for acting out behavior in the classroom. Student has history of anxiety and expressed feeling stressed out on center and difficulty with peers. Introduced distress tolerance activity to increase awareness of feelings and how to express them in a more positive way. Student agrees to journal and will return in 1 week.

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Sample Employability Progress Note

S = Student reports having difficulty sleeping in the dorm along with feelings of sadness and disinterest in center activities over past two weeks. Student states he is becoming increasingly irritable during the day.

O = Student was generally anxious throughout the session with a flat affect. At one point became tearful and slightly agitated. Able to verbalize how current symptoms could become barriers to employment if not resolved. Denied any suicidal thoughts or past suicidal behavior.A = Student has been on center for two months and is experiencing adjustment issues which may be triggering an episode of depression. Shows moderate level of motivation to address symptoms, identify, and remain in program. P = Schedule next appointment for 5/10/2014 @ 3:30pm to begin short-term cognitive behavior therapy to address symptoms on center and provide strategies on how to handle emotions on center and in future work environment. Gave student sleep hygiene brochure and instructed to return to wellness if problems do not get better before next appointment. Refer to Counselor’s adjustment group, alert RA and Counselor to watch for behavioral changes over the week and refer back to health and wellness, if needed. Lastly, student given mindfulness exercises to practice over next week.

CMHC, Ph.D. # 1010

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Assess/Info Gather Psycho-education Motivational Interviewing Crisis Intervention Stress Management CBT/ACT Empathic Exploration Social Skill Training DBT/Mindfulness Decision Making Psychodynamic/Relational Other

INTERVENTIONS FOR EMPLOYABILITYIndicate primary types of interventions utilized (Check all that apply). Describe in summary of session.

Sample Progress Note

SUMMARY (Include how the session ties into employability or the work environment for the student) Session Phone contact Case Management/Consultation Other

____________________________________________________________________________________________________________________________________________________________________________________________________________________________

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(d) Treatment Con’t Collaboration with TEAP

Minutes of meetings Collaboration with CP - Psych Meds

Note on chronological record or note in MH section of SHR Standing meeting with CP and/or Wellness staff

Collaboration with Counseling staff in developing and/or leading psycho-educational groups Schedule of groups on center provided by counseling If you referred student to group, should be indicated in the

SHR- MH section If you are conducting a group, should be indicated in the

SHR

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Documentation of Case Conferences and CMHC Led Groups

Pre-printed adhesive labels that allow enough space for brief sentence update. Signed and dated

Emotional Regulation GroupStudent was active in group and participated in deep breathing exercise.

5-1-2014 CMHC, PhD.

Case Management MeetingStudent continues to attend anger mgt. group and is doing well. No further MH services needed at this time. 5-1-2014 CMHC, PhD

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(d) Treatment Con’t Regular case conferences between CMHC, Counselors, and other

appropriate staff- Case Management Documentation of Case Management and Feedback Form (DRG) in SHR

in MH section Progress Note in MH section

Referral to Off Center- Case Management Release of Information to exchange updates Work with Wellness staff to come up with system to document off

center updates in the SHR

Written referral and feedback system- Case Management Use of Referral and Feedback Form (DRG)

Provide feedback to the referral source at the bottom of form. Copy in SHR Follow-up on feedback at next case conference and document in SHR

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Care Management vs. Case Management

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Care Management

PRH requirement [PRH-6.10: R1, 4] states “students identified as having chronic health problems during the cursory or entrance physical shall be monitored as directed by the CP or other appropriate center health provider.”

What CMHC tasks are considered care management?

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Case Management

PRH requirement [PRH 6.10 R3, d5] states “Information exchange through regular case conferences between the Center Mental Health Consultant, counselors, and other appropriate staff based on individual student needs.”

Case management requires communication among staff, monitoring, and follow up

We do not recommend the use of CIS by CMHCS

21 Chapter 5 and Training

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Chapter 5 - Exhibit 5-4

Centers shall include, at a minimum, the following: a. Five hours of annual training in adolescent

growth and development for all staff. Topics could include effective communications, anger management, sexuality, suicide prevention, behavior management system, zero tolerance policy, appropriate staff/student boundaries, sexual assault prevention and response, sexual harassment and related social skills training, crisis intervention techniques, bullying prevention, violence prevention, and safety issues.

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Best Practices that Make Assessors Happy!

Document, Document, Document Smartly!

Have documentation organized and available.

Include discussions on how emotions and behaviors impact employability with students and document in progress notes.

Include documentation in the file on students discussed and updated during meetings with counselors.

Consistently provide information back to the referral source with a copy easily found in the SHR.

Notation on Chronological Record in SHR “May 1, 2014 - See Note in

MH Section”

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In A Nutshell

SHR - MH Section Social Intake Form Referral and Feedback

Form Specifics for Referral

Source Intake Assessment

MHCCMP RAC

Employability Progress Notes

Case Management Notes On and Off site

Med-Check in Notes Group Notes

Mental Health Promotion and Education Binder CPP, CDP, and CTP

Presentation Info Documentation of center

wide activity Documentation of any

staff trainings

Chronological Record Document dates students

receive services with corresponding note in MH section.

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Regional Mental Health Specialists

Region 1 David Kraft, MD, MPH

[email protected] Maria Acevedo, PhD (PR

Centers [email protected]

Region 2 Valerie Cherry, PhD

[email protected] Region 3

Suzanne Martin, PsyD, MPH [email protected]

Region 4 Lydia Santiago, PhD

[email protected] Region 5

Helena Mackenzie, PhD helena.mackenzie530@

gmail.com Region 6

Vicki Boyd, PhD [email protected]

Mental Health and Wellness Program

Documents

Transcript of Mental Health and Wellness Program