Recovery Planning in Behavioral HealthCan we honor the person and still satisfy the chart?

Janis Tondora and Dan WartenbergMHTTC Webcast

June 5th and June 19th, 2019

Introductions & Housekeeping

Janis Tondora, Psy.DAssociate Professor, Yale Program for

Recovery and Community Health

Dan Wartenberg, Psy.D., M.P.H.Chief Clinical Officer,

Newport Mental Health

Agenda – PCRP Webinar SeriesJune 5th

• Introduction and Background

• 4 Ps Key PCRP Practices

• Preview of documentation

• Implementation barriers• Lessons learned in implementation

• Leadership commitment

• Competent, motivated workforce

• Organizational infrastructure and work flow

• Activated/empowered clientele

June 19th

• Deeper dive into documentation

• Person-centered assessment

• Core documentation elements & common quality errors

• Writing a plan that honors the PERSON and satisfies the CHART

• Lessons learned in the design of EHRs platforms and planning templates

• Promise and pitfalls of EHRs in supporting (or undermining!) person-centered thinking and practice

RegulationsRequired Paperwork

Medical NecessityCompliance

CollaborativePerson-CenteredStrengths-based

Transparent

…and in a way that balances the spirit of person-centered care with the rigor required in plan documentation?

Irreconcilable differences, happily ever after… (or at least a peaceful co-existence?)

“Let’s face it – our relationship is doomed!”

PCRP Documentation: What Does It Look Like?

The Plan is Only as Good As Your Assessment

• Assessment is enhanced around commonly neglected areas:

• strengths/interests

• cultural preferences and treatment implications

• stage of change/readiness• AND concludes with an integrated summary that goes beyond the data to

capture a more holistic understanding of the person and their story!

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Big Picture View PCRP Elements

GOALas defined by person;

what they are moving “toward”…not just eliminating

Strengths/Assets to Draw Upon

Barriers /Assessed Needs That Interfere

Short-Term ObjectiveS-M-A-R-T

Interventions/Methods/Action Steps•Professional/“billable” services•Clinical & rehabilitation•Action steps by person in recovery•Roles/actions by natural supporters

Problem-CenteredOne Goal for Every Problem as

Identified in the Assessment

Person and Goal-Centered Goal of the PERSON and

How Barriers Interfere

Subtle But Important Differences in Quality

• Problem: Assaultive behavior• Goal: Assault free x 1 month

• Problem: Poor hygiene/self-care• Goal: Shower/bathe regularly

• Problem: Substance use• Goal: Abstain from alcohol x 2

weeks

• Problem: Auditory Hallucinations • Goal: Increase reality testing

I want my job back so I can provide for my kids.

• Impulse control issues led to physical conflict with co-worker and termination.

• Self-care improvements needed to present well in job interviews.

• Substance use led to frequent absenteeism and job loss

• Auditory hallucinations make it difficult to interact with customers at retail job.

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Goals: What Do People Want?

IndependenceI want to control my own money.

Work /educationI want to finish school

Spiritual connection I want to get back to church.

Health/well-being I want to lose weight.

To be part of the life of the community…

HousingI want to move out of the group home.

Social activities I want to join a bowling league.

Satisfying relationships I want to see my grandkids.

Valued Roles I want to volunteer at the Senior Center.

And NOT just traditional treatment plan goals…

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• Goal: Maintain psychiatric stability

• Objectives1. Compliance with meds2. Attend appointments with primary care

provider 3. Attend all psychiatric appointments as

scheduled

Long term, global, and broadly stated Life changes as a result of services Ideally expressed in person’s own

words Written in positive terms Consistent with desire for self-

determination influenced by personal world

view

Challenges in Goal Setting• The process of goal development takes time and a trusting relationship

• Not all people can easily articulate personal goals/desired results

• Goals often unfold through reflective listening that highlights key things you note seem important to the consumer• It’s OK to make a suggestion to get the ball rolling!

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• A person’s goals may change!

• The language of goals and goal-setting can be intimidating!• Go back to your SBA: Visualize an “ideal day” - what

would this look like? What would you be doing? Who would you be with? If you had a magic wand…

Strengths

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• Identifies aspects of the person’s life that they can draw from to move toward a specific goal

• Promotes engagement and communicates message of hope and confidence in the person’s abilities

• Captures the person’s unique identity, resources, interests

• best qualities/motivation

• strategies already utilized to help, self-directed wellness

• competencies/accomplishments

• cultural traditions and connections

• community and social relationships

• environmental factors that will increase the likelihood of success

Capitalize on Strengths in the Plan

• e.g., a person with a love for books might be engaged by asking him/her to help out in the agency library… a person who loves music might benefit from access to CDs/headphones as away to quiet voices… … a spiritual person contemplating suicide might want direction from a Spiritual Director… an animal lover struggling with obesity due to med side effects might walk a dog regularly

Barriers

• In order to inform and individualize the plan, it is important to be explicit and describe not just WHAT is getting in the way, but HOW…

• What is getting in the way of the person achieving their goal?

• Why can’t they do it tomorrow? • What prevents them from doing it on their own?

• Consider: • need for skills development, intrusive symptoms, lack of resources, problems in behavior,

difficulty in activities of daily living, disruptions in meaningful relationships and roles, threats to basic health and safety, challenges/needs as a result of a mental/ alcohol and/or drug disorder; diagnosis alone is NOT the barrier

Descriptive Detail Beyond Generic “Labels”

• Henry is schizophrenic Henry says he’s hearing a lot of voices today. We talked about what the voices are saying, how that feels, and how its been a problem at work.

• Jill is depressed Jill is having a really hard time getting out of bed lately. She says she just can’t stop crying and feels afraid to leave her house.

• Margaret is labile Margaret went back and forth between crying and laughing several times in our conversation, and couldn’t say why.

• Mary is a cutter Mary sometimes cuts herself, and has explained that it’s a part of how she copes with her emotional pain.

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Descriptive Barriers Connect the Dots Back to the Goal

• Anger issues

• Depressive symptoms

• Addiction

• Outbursts and conflicts with neighbors

• Lacks the energy to take care of basic household tasks

• Substance use at apartment has led to police calls and risk of eviction

Weak Examples Strong Examples

Short-term Objectives:What do they do?

• Concrete, positive CHANGES in behavior/functioning/status

• Divide larger goals into manageable steps of completion

• “Proof” you are getting closer; help to assess progress; is all your LINKING working?

• Send a hopeful message we believe things can, and will, be different for the better!

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Objectives Should be SMARTHere’s a way to evaluate your objectives. Are they SMART?

• Simple or Specific• Measurable• Achievable• Relevant• Time-framed

Will you definitively be able to say, was it achieved, yes or no…?

Technical Formula for Crafting Objectives

Examples:Within_______(amount of time), (insert name)_________

will have improved (insert documented barrier) ____________, as evidenced by________ (insert a meaningful change in functioning or behavior that is related to

the life role goal.)

• Phillip will have increased social interaction as evidenced by meeting a friend for coffee at Dunkin Donuts at least one time per week within the next 30 days.

• Within the next 30 days, John will have improved management of panic as evidenced by successfully riding the subway to work without exiting the train before his stop.

Objectives Are About Outcomes NOT Service Participation

• The following objective is about service participation. People can participate in services for years and not achieve the intended benefits!

• Wanda will voluntarily attend DBT group 2x weekly.

• Objectives are about what you hope will change for the person as a result of services & the person’s hard work:

• Wanda will apply mindfulness techniques to reduce instances of self-injury to no more than one per week for 2 consecutive weeks.

Interventions/services & Action Steps

• Reflect a use of EBPs

• respect individual choice and preference

• describe medical necessity by clearly describing how services are intended to overcome that individual’s barriers

• are specific to the individual’s objective, no “kitchen sink” service sets

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• The plan serves as a contract for who is responsible for what actions

Critical Elements – The “Ws”

• Professional services should specify…

• WHO will provide the service, i.e., name and job title

• WHAT: The TITLE of the service, e.g., Health & Wellness Group

• WHEN: The SCHEDULE of the service, i.e., the time and day(s)

• WHY: The individualized INTENT/PURPOSE of service

Interventions: Self Directed and Natural Support Actions • Self-directed actions are a

reminder that the consumer, too, has a responsibility in contributing to the recovery plan.

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• Natural Support actions reflect the growth of the informal recovery network that supports the person’s recovery over time.

Gerry lives with a diagnosis of disorganized schizophrenia and has spent years off/on in the state hospital. He is currently living in a 24-7 monitored residential group home. Gerry reports he is very lonely. He used to go to the downtown jazz fests and meet lots of people, but now he feels like a “zombie.” He is not getting out of the house to do much of anything other than come to the Center. He wonders if this is due to his meds or something else… Although he would like a girlfriend, Gerry admits to being “terrified” to get out in community and meet women, and states that its been 10 years since he dated anyone. He wouldn’t know where to start…He is currently unable to take the bus and is afraid to go anywhere alone because he often gets confused or fears others might try to hurt him.

POLL: So what do you think? Which of the below is the best goal statement for Gerry’s PCRP?

1. I don’t want to feel like a “zombie.” 2. Gerry will better manage distressing symptoms of paranoia. 3. I want a girlfriend. 4. Gerry will attend the Social Skills Group.5. I just want to be happy.

Goal: I want a girlfriend…someone to share my life with. • Strengths:

• Motivated to reduce social isolation; supportive brother; has identified community interests he enjoyed in past (e.g., music, Chinese restaurants) well-liked by peers; humorous

• Barriers/Assessed Needs/Problems: • Intrusive thoughts; can feel threatened by others in social situations; possible negative symptoms

of schizophrenia and/or med side effects result in severe fatigue/inability to initiate (social isolation); easily confused/disorganized; need for skill development to: use public transportation/increase community mobility, develop symptoms management/coping strategies, challenges in communication and social skills, difficulty with self care routine

• Objective:• Gerry’s comfort around others will improve as evidenced by his participation in a minimum of 1

preferred social activity (outside the group home) per week for the next 90 days

Gerry’s PCRP

• Jane Roe, Clinical Coordinator, to provide CBT 2X/mos. for next 3 mos. to increase Gerry’s ability to cope with distressing symptoms in social situations (teaching thought stopping, distraction techniques, deep-breathing, visualization, etc.)

• Dr. X to provide Med Management, 2X/mos for next 3 months to evaluate therapeutic impact and possible side effects to reduce fatigue and optimize functioning

• John Smith, Peer Coordinator, will provide travel training 1X/wk. for 4 weeks to help him become independent with city bus (e.g., identifying most direct bus routes, rehearsing use of coping skills, role playing conversations if confused/lost, etc.)

• Gerry’s brother, Jim, will accompany Gerry to weekly social outings over the next 3 months.

• Gerry will complete a daily medication side-effect log for the next 2 months while meds are evaluated and adjusted.

Interventions & Action Steps

Take home message… • You CAN create a recovery plan which honors the person and

satisfies the chart!

• This is central in your partnership with individuals so they can move forward in their recovery in the community of their choice!

• We just need to stop accepting what is and start creating what should be…

Dale DiLeo

But what about our EHR…?

Implications for Treatment Planning Components in the Design of Electronic Health Records

PCRP and EHR Planning Templates: A Common Dilemma

Poll QuestionsDo you currently use an EHR to do your recovery planning?1. Yes2. No

If yes, would you say that your EHR1. makes it easier to write a person centered plan2. has no impact on making my plans person centered3. hinders my ability to write person centered plans

Considerations in Plan DesignThe structure reflects the principles of person centered care• Goals drive the plan, problems are understood as barriers to reaching the

person’s life goals

• The plan is created through a dialogue where both the person and practitioner have the opportunity to weigh in. Place to document “agreeing to disagree”.

• Integrates the use of strengths to overcome barriers

• The ordering of info/sections: hopes/dreams/strengths… up front rather than leading with diagnosis

• Fields for documentation of natural supports contributions as well as self directed actions by the individual

Considerations in Plan DesignA person centered recovery plan is an individualized plan• Tension between efficiency and guaranteeing compliance vs. a

descriptive individualized plan– Drop downs vs. open text

– Hard-wired logic vs. flexibility

– Impact of auto-populating libraries with pre-set text

– “Domain-based” planning structures which require users to rigidly classify, and then separate, goals into discrete categories.

• Optimal EHR design is never a substitute for critical clinical and patient-centered thinking!

Considerations in Plan DesignThe recovery plan is easy to use• Efficient, easy to navigate user interface

• Easily amendable to reflect changes over time, challenge of “living document” vs. point in time plan

• Training and Staff Uptake

– Include PROMPTS/POP UPS for the user regarding expected input across multiple (sometimes overlapping) fields, “open book test”

– Create and use “prototype” person-centered plan to show exactly how to reflect content within the EHR

Considerations in Plan DesignThe recovery plan is integrated• How do other documents in your EHR reflect the principles of PCRP

• How are assessments worded

• Pulling goals or objectives into progress notes

• Opportunities to promote patient activation and illness self-management

• Ability to pull-in or reference other documents or data (advanced directives, crisis management plans)

• Opportunities for direct client input through a portal system, measurement-based care

Sample Prompts/Format

Recovery Goal: A statement of the overall goal, in the participant's own words, expressing a desired change, improvement, or recovery outcome

Additional Staff comments (if needed): When necessary, use to clarify the person's goals or to reflect the staff perspective when there is significant disagreement

Strengths and Resources: Skills, qualities, or experiences that may help the person achieve their goals. Consider values, areas of interest, strengths, and personal, and community supports.

Personal/Clinical Barriers: Problems/needs/functional impairments/skill deficits from the assessment that interfere with goal attainment, with a particular focus on those needs directly related to mental health and/or addiction issues

Systemic/Environmental Barriers: Practical/systemic/and resource issues (e.g., no transportation to clinic, services not available in primary language, wait lists for preferred program, etc.).

Sample Prompts/Format

Objective(s): Concrete steps that will be proof that the person is overcoming a mental health/addictions barrier and making progress toward his/her goal

Services to be provided by Agency: The range of clinical and rehabilitative services offered by your agency that will help the person to overcome his/her mental health/addiction barriers and achieve his/her objectives.

Desired improvement in identified barriers:

As evidenced by: (e.g concrete accomplishment or change in functioning)

Target Date of completion

Service Type Provider type Frequency Duration Service DescriptionObjective(s) to be addressed

Sample Prompts/Format Assistance to be provided by Community or Natural Supports and Other Providers: Other people (external to your organization) who have important contributions to make to the individual's recovery plan. This should include professionals (e.g., a medical doctor, a probation officer, an employment specialist, school counselor, etc.) as well as natural supports (e.g. family member, friend, employer).

Concerns raised during assessment, not specifically addressed in the plan. Reason(s) as to why the concern is not included:

Personal Wellness Strategies: Things done on a regular basis to manage stress and optimize wellbeing, ideally linked to personal strengths/interests

Person Providing Support/Services Nature of support

Pop-Ups/ Help Text Built Into EHR Fields

Link to Personalized Crisis Plans (*only if indicated)

• Risk-management through a recovery-oriented lens

• Can link to external databases and or/ Psychiatric Advance Directives (PAD) and PAD educational resources

• Flagged in medical record so readily accessible

• Increasing potential to upload PADs through patient portal technology

Sample Assessment Questions1. Relationships Who are the most important people in your life right now? Are there people you can turn to when things get difficult? How are your friendships going? How are your family relationships going? Do you have (or hope to have) a romantic or sexual relationship-how is this going? Are there people that depend on you (children, elderly relatives)? Who are the people you turn to in times of difficulty? ____________________________________________________________________________________________________________________________________________________________ What are your goals for forming or improving relationships? ____________________________________________________________________________________________________________________________________________________________ What are the barriers to forming or improving relationships (e.g. I am shy, I haven’t talked with my family for years, I don’t know how to meet people)? ___________________________________________________________________________________________________________________________________________________________ Staff comments: ____________________________________________________________________________________________________________________________________________________________ Consumer Preference Staff Suggestion Decision

1. __ Work on Now 2. __ Work on Later 3. __ Not a focus

1. __ Work on Now 2. __ Work on Later 3. __ Not a focus

1. __ Work on Now 2. __ Work on Later 3. __ Not a focus

Building a Recovery Team

Important persons in life and recovery Please help me make a list of all of the people that are important to you or can help you in recovery and think about how they could help you in your recovery. (Include friends, family, employers, clergy and other persons and groups as well as clinicians and providers). Name

Relationship to you

How they could help with my recovery?

Contact OK?

A Concluding Thought

• Even the best of designs will not result in quality documentation in the absence of meaningful content and technical training, i.ee., “traditional” content can still be forced into the most patient-centered of designs

Closing Q & A… Your Thoughts and Ideas

For more information:janis.tondora@yale.eduwartdan@optonline.net