Care Planning and Documentation in Integrated Health
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Care Planning and Documentation in
Integrated Health
M
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Judith Anne DeBonis PhD
Department of Social Work
California State University Northridge
M
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By the end of this module students will:
Recognize the importance of the care planning process in IH
Understand the differences between treatment plans, care
plans, and action plans
View the care planning process as an opportunity for creativity,
discovery, and learning for both the patient and the provider
Match and use empowering techniques in the implementation
of a shared decision-making care planning process
Acquire and utilize skills to enhance patient goals setting
View care planning as a dynamic process involving ongoing
updates and evaluation
“If you grew up in a small town
…at a time when
the family
doctor would still make
a house call…”
Traditional Medical Model…
1
Today—
Patients are expected to be:
1.
Informed
2.
Proactive
3.
Participate as
a partner
“The recipient of services
must be the driving force in
the development of a plan
that articulates a vision of
recovery”
3
Newer Patient Centered Chronic Care Models
2
Treatment Planning
3
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•
A time-consuming paper exercise
performed to meet administrative or
accreditation requirements.
•
Disconnected, inconsequential with
respect to what really happens in treatment
•
Little to no impact on outcome.
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•
Accurate understanding of the
individual needs, strengths,
goals discovered through the
alliance
•
A roadmap that shapes and
forms both the process and the
product of treatment
Not just filling in forms—the
“new” plans are informed,
individualized, and built
from creative thinking
Treatment Plans, Care Plans, Action Plans
4
Formal written plans can help to organize the work of teams and
help patients to navigate the complexities of multidisciplinary care.
5
1. Treatment Plan
Doctor’s orders and
recommendations with
regard to the patient’s
medical care
2. Care Plan
Based on the doctor’s
orders, the plan that the
care manager and
patient design in
collaboration with the
health team
3. Action Plan
That portion of the care plan
that the patient will
implement at home.
Contains individualized
instructions that the patient
has collaborated to develop.
Documents produced from the treatment planning process differ widely in definition and purpose
The care plan, created collaboratively by the health team,
bridges the doctor’s orders and the patient’s personal goals
Individualizing the Care Plan
4
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The patient is
considered the most
important member of
the health team
Both Patient & Provider Expertise Needed
6
Healthcare
professionals are
the expert on
health practices
Patients are the expert on their life
What is important to me
What I am willing to do
What health actions I take
For the patient, information may not be enough—skills
and confidence are also needed to participate fully.
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An interactive, collaborative process between providers and consumers that is
used to make healthcare decisions in which at least 2 individuals work together
as partners with mutual expertise to exchange information and clarify values in
relation to options and thereby arrive at a discrete decision.
P
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Practitioner as a consultant to the
consumer
–
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Shared Decision Making (SDM)
7
G
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A
L
A person-centered, supportive
encounter which promotes the
ideal conditions for effective
decision making to occur
Consumers are empowered with
information so that their
autonomy or control over
healthcare decision making is
increased
How SDM Supports Patient
Empowerment and Participation
7
In the shared decision-making process, practitioners
are encouraged to think about and apply:
1.
Self-directed care
2.
Self-determination
3.
Person-centered planning
For consumers to participate fully as partners in a
shared decision making process, they will need to
information, skills, and confidence
Steps in a Shared Decision Making Process
7
1.
Recognition that a decision needs to be made
2.
Identification of the partners in the process as equals
3.
Statement of options as equal
4.
Exchange of information on pros and cons of options
5.
Exploration of understanding and expectations
6.
Identifying preferences
7.
Negotiating options and concordance
8.
Sharing the decision
9.
Arranging follow-up to evaluate decision making outcomes
S
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-
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9
Decide what the
person wants instead
of what they don’t
want—when what the
person is doing is not
working, have him or
her do something
different.
S
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8
In contemplation:
aware of the
problem, but
ambivalent about
making a change
Recognition that a decision needs to be made
7
Matching Techniques and Approaches to
the Shared Decision Making Process
E
m
p
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6
Identification
of
something YOU (the
patient) want to
accomplish or a
problem that you want
to resolve
1
“
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f
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9
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Amplify and build on
strengths to promote
change in areas identified
by the person and the view
he/she holds for wanting
things to be different
Practitioners and patients
construct the solutions
together …sometimes
inventing them
S
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8
,
1
1
Providers respect the
particular needs of
persons in various
stages and adjust their
stance (nurturing
parent, Socratic
teacher, coach,
consultant) to support
specific actions
necessary for the
person to progress to
the next stage
Identification of the partners in the process as equals
7
Matching Techniques and Approaches…
E
m
p
o
w
e
r
m
e
n
t
6
Persons are allowed to
direct their own course,
focusing on one or two
items that fit their interest
or need
This process will generate
feelings of self efficacy,
competence and build
confidence
2
S
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F
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9
There are always
solutions
There are more than
one solution
S
t
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C
h
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e
8
Each person will
weigh a personalized
set of pros and cons,
choose from a
variety of change
processes, and
choose among
strategies for
combating specific
temptations
Statement of options as equal
7
Matching Techniques and Approaches…
E
m
p
o
w
e
r
m
e
n
t
6
Brainstorming offers
multiple ideas for
discovering new and
creative possibilities.
There are no right or
wrong responses. All
ideas are accepted
and believed to hold
potential.
3
S
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F
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9
Exceptions for every
problem exist and once
discovered can be used
to build a solution and a
different view
Helping the person to
select the changes that
will help them become
more of what they like
and want to see continue
S
t
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C
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a
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e
8
Supporting the
accumulation of
personal reasons
and benefits of
change (pros) is
necessary to shif
t
the decisional
balance from the
costs of change
(cons)
Exchange of information on pros and cons of options
7
Matching Techniques and Approaches…
E
m
p
o
w
e
r
m
e
n
t
6
Based on ideas
generated from a
brainstorm—do any of the
options seem workable
for an individual’s
problems? Explore those
options in detail.
4
S
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F
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9
What will the change look
like? How will things be
different?
Examining the details
about how the change will
feel, what will be noticed
first when it occurs?
S
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C
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e
8
I
n preparation, taking
time to explore
options and
experiment can
support individuals to
choose a plan
Understanding
relapse is part of the
process of change
can encourage use of
prevention tools
Exploration of understanding and expectations
7
Matching Techniques and Approaches…
E
m
p
o
w
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r
m
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n
t
6
Setting goals that are small
enough to be accomplished
in one week is usually a
reasonable expectation
Persons must have at least
70% confidence that they
can accomplish the goal in
1 week—an indication that
the goal is reasonable and
success is likely
5
S
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d
9
,
1
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Instead…what would you
rather have?
How will you be doing
this?
As you leave here today
and you’re on track, what
will you be doing different
or saying different to
yourself?
S
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f
C
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a
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e
8
Deciding when to
change, choosing
the
plan, the best
tools and support for
coping with
setbacks, all is
based on individual
preferences
Identifying preferences
7
Matching Techniques and Approaches…
E
m
p
o
w
e
r
m
e
n
t
6
Goals and actions taken
to accomplish them are
person-specific; there
are
many different paths and
strategies that can be
successful
6
S
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9
,
1
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Small changes lead to
larger changes—
facilitates an easier way
and simpler path to
change
What will make it
worthwhile that you spent
this hour here?
S
t
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o
f
C
h
a
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g
e
8
In all stages, change
processes –putting
the focus on either
thinking/feeling or
behavior/doing are
optional techniques to
be applied to the
process—in
agreement with the
goals of the stage.
Negotiating options and concordance
7
Matching Techniques and Approaches…
E
m
p
o
w
e
r
m
e
n
t
1
,
6
Lower confidence levels
can indicate that the goal
should be renegotiated to
a smaller step which has
a greater change to be
successful.
Look for teachable
moments where there is
more openness to new
information.
7
S
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F
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d
9
What would others say
about the benefits of this
change for you?
How have you been able
to decide this?
How will your change
effect others?
S
t
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o
f
C
h
a
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g
e
8
Solidifying the
commitment to
change often means
sharing a plan with
support network
At each stage
decisions are made to
take actions that can
progress the person to
the next stage.
Sharing the decision
7
Matching Techniques and Approaches…
E
m
p
o
w
e
r
m
e
n
t
1
,
6
Tell people about your
goals so they can provide
support
The best feedback can
come from others who
also are managing a
chronic condition
8
S
o
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n
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F
o
c
u
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e
d
9
If something is not working,
do something different.
Build on exceptions to the
problems. Amplify small
successes.
Miracle question response
provides a detailed view of
the change with specific
indicators to watch for and
reinforce.
S
t
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f
C
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e
8
,
1
1
In action—”consultant”
helps to monitor
progress; offers a boost
when progress is stalled
and supports design of
relapse prevention plan
In maintenance—
preventing relapse,
sustaining new behavior
still requires
commitment, energy.
Arranging follow-up to evaluate decision making outcomes
7
Matching Techniques and Approaches…
E
m
p
o
w
e
r
m
e
n
t
6
Review goal progress in 1
week; if successful,
continue.
Use brainstorming and
problem-solving for
discovering alternatives
9
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A way to turn a goal
that you want to
accomplish into a
specific plan with steps
B
r
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s
t
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i
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g
A non-threatening way
to generate a list of
new ideas
P
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S
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g
A process of self
discovery and active
engagement to explore
options that lead to
success
Lorig
23
Three Empowering Techniques
6
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Is reasonably accomplished in 1 week
Is behavior-specific
Answers: What? How much?
When? How often?
Begins with your confidence level at 7
or more (otherwise, renegotiate)
Action Planning
6
A Successful Action Plan…turns goals into doable steps
D
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Value of Setting Goals
3
Receive support, encouragement, a sense of hope
Understand what specific results can be expected from
treatments
Feel more motivated to participate in decision-making about
their health
“There is perhaps no greater expression of respect, understanding, hope, and
empathy by the provider than the ability to elicit, acknowledge, and accept the
individual and family goals”
3
1
2
3
Patients who identify and bring personal goals to the attention of
healthcare providers can:
C
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r
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b
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i
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s
9
•
Helps identify strengths to be
built upon
•
Promotes expectation that
small changes will lead to
bigger changes
•
Instills hope that change is
possible
•
Empowers changers
F
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G
o
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s
:
1
0
Give a positive statement—
what the
person will be doing or thinking rather
than what they will not be doing or
thinking
Work with the person to describe
specifically (in concrete terms)what the
process will look like. “Can you tell me
more specifically how you will be doing
that?” “What will you be doing when that
happens?”
Use the person’s words and language.
Solution-Focused Techniques
Solutions are a Type of Goal
9,10
2
1
3
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pecific
easurable
ttainable
ealistic
imely
small
changes
with a
big
impact
SMART and Specific
Using Smart Goals to Specify Objectives
3
Detail: Smart Goals
3
E
x
a
m
p
l
e
s
Deciding not to
read the paper until after
exercising
Buying only 2 pieces of a
favorite fruit at a time and
walk the ¼ mile to the
market each day for more
Using money saved from
not buying cigarettes to
buy yourself something
The real reward is a fuller and
healthier life
Self-reward frequently
Add enjoyment to life―it’s part of
the goal
Give yourself some “time off”—
Do something 3 times a week for
10 minutes rather than every day
Write down the goal ― tell others
Note progress weekly
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Rewards as Part of Goal Setting
Personalizing Rewards to Enhance Motivation
6
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?
Using Lorig’s ideas for successful Action
Planning, how would you examine the
goal and describe:
How it fits the Lorig model
How would it need to be adjusted
Was the consumer successful? How
does the Lorig model help when the
person has no goal?
Action Planning - Activity
Making an Action Plan
T
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s
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”
Brainstorming
6
A
c
t
i
o
n
s
Generate a question
Share ideas through
brainstorming
Dialogue
to
determine if
any of
the
ideas
might be
used to help
Make an action plan
P
r
o
b
l
e
m
Someone you’ve
worked with is
struggling with an
obstacle to changing
their behavior.
You and the person
are at a loss as to
how to proceed
Brainstorming - Activity
Role Play Using Brainstorming
I
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Problem Solving
6
S
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p
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6
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7
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’
s
d
i
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c
u
s
s
How do you help them to put their
goals into the SMART format?
How often do consumers set their
goal as a series of small steps?
Do you encourage setting up a
reward plan?
What would you imagine the person
would answer: How will you know
when it’s time to make a change?
What do you imagine will happen if
you continue on as you are?
Problem Solving - Activity
T
h
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k
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Problem Solving
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-
M
a
k
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g
P
r
o
c
e
s
s
Team Role in Treatment Planning
3
The plan is the “glue” that holds the team together and
supports its success—coordination is essential
The team is a group of people all working toward a common
goal—developing a plan that responds to the unique needs
and desires of an individual and family
Both the team and the plan will need to be adaptable to
change as the planning of care is a dynamic process
“A part of the commitment to person-centered care is attending to the process of
developing, documenting and implementing an individual plan”
3
1
2
3
“The provider role is no longer all-knowing caregiver, but
instead coach, architect, cheerleader, facilitator, and shepherd.”
3
E
n
g
a
g
i
n
g
F
a
m
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a
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l
a
n
n
i
n
g
P
r
o
c
e
s
s
Involvement of Family and Friends
3
Serve as a reminder of history, which while painful, might
communicate a message of hope about earlier goals
Respect for the individual and family/friends is essential; each
is offered choice about the most comfortable way to
participate and their preferences are accepted
May need to process past experiences and feelings, both
good and bad, with regard to seeking treatment
“The family is a vital source of information and knowledge about the
individual, their history, and needs, the role of culture in their lives, and
other important details. Also, physical and emotional support of family
can be a critical component of each individual's recovery”
3
1
2
3
W
r
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t
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n
g
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f
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l
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M
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d
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c
a
l
R
e
c
o
r
d
s
1
3
Record individual status and progress while also
allowing for population dashboard data for
decision support around key areas of interest:
A
l
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m
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/
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r
s
Documentation and Communication
12
C
o
m
p
l
e
x
C
o
n
s
i
d
e
r
a
t
i
o
n
s
:
1
2
For metrics and measurements to be
used effectively, information and
data need to be collected, stored,
easily accessed and presentable
to those who will access them.
Record policies, development of
electronic health records and
communication about data all need
to be addressed
T
i
m
e
l
y
a
n
d
c
o
n
c
i
s
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o
l
l
a
b
o
r
a
t
i
o
n
Communication between all providers is most effective and efficient when it is readily
available, referred to and utilized with the consumer.
Computer competence is an essential skill for social workers in IH
What’s your note preference? PIE, DAP,
or SOAP?
4
Formats to help with writing a clear and concise progress note
P
I
E
P
r
o
b
l
e
m
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n
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n
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v
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l
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a
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D
A
P
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s
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o
n
,
A
s
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s
s
m
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n
t
,
P
l
a
n
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O
A
P
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O
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t
i
v
e
,
A
s
s
e
s
s
m
e
n
t
,
P
l
a
n
All structured and all require assessment as part of the note
Can “problem-oriented” notes be used effectively to support an
objective-oriented and recovery-oriented record?
Well written notes in Integrated Health are SHORT and TO THE POINT!
Benefits of Well Written Notes
“Including a mini assessment is beneficial in that it keeps all
providers clear and focused on the individual needs and
desires of the consumer”
3
A
W
i
n
-
W
i
n
3
With good documentation it is more difficult to
provide ineffective services for an extended
period of time.
•
T
h
e
l
a
c
k
o
f
p
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g
r
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…
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t
e
a
m
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e
v
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a
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e
•
I
f
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v
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,
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…
a
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d
d
i
t
i
o
n
a
l
f
o
r
w
a
r
d
m
o
t
i
o
n
Medical records
tell the story of a
person and any
reader should
come away with
an better
understanding
U
p
d
a
t
i
n
g
t
h
e
C
a
r
e
P
l
a
n
Ongoing monitoring, reviewing
and re-evaluation of goals
3
Assessment and reassessment
allows for information gathering
which can help to evaluate and
monitor progress, modify and
update the plan as needed
Periodic review of the treatment plan:
1. Keeps the plan accurate and up-to-date
2. Helps maximize benefit from treatment
interventions by determining what is working
and what needs adjustment
Review may:
•
Highlight areas of strength that can be used to
increase positive outcomes in other less
successful aspects of treatment
•
Offer an opportunity to brainstorm about areas
that are problematic and make choices for next
steps
May uncover
other barriers to
treatment
success that
have not been
identified
C
o
n
s
i
d
e
r
i
n
g
M
e
d
i
c
a
l
N
e
c
e
s
s
i
t
y
S
t
a
n
d
a
r
d
s
a
n
d
R
e
q
u
i
r
e
m
e
n
t
s
Administrative Requirements
3
D
i
s
c
u
s
s
i
o
n
P
o
i
n
t
:
How can medical necessity
requirements protect and
help consumers and
families?
In what ways might these
requirements be
inappropriately applied and
cause denial of services?
5
C
o
m
p
o
n
e
n
t
s
o
f
M
e
d
i
c
a
l
N
e
c
e
s
s
i
t
y
:
3
1.
I
n
d
i
c
a
t
e
d
…
w
h
e
r
e
t
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e
r
e
i
s
a
d
i
a
g
n
o
s
i
s
2.
A
p
p
r
o
p
r
i
a
t
e
…
m
a
t
c
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b
e
t
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s
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e
a
n
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d
3.
E
f
f
i
c
a
c
i
o
u
s
…
l
i
k
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l
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f
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t
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4.
E
f
f
e
c
t
i
v
e
…
d
e
t
e
r
m
i
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i
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g
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s
p
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d
5.
E
f
f
i
c
i
e
n
t
…
w
h
e
n
s
e
r
v
i
c
e
s
a
r
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a
p
p
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o
p
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a
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,
e
f
f
i
c
a
c
i
o
u
s
,
a
n
d
e
f
f
e
c
t
i
v
e
What services and
where services are
provided and at
what level of care
Documenting Medical Necessity
D
o
n
’
t
F
o
r
g
e
t
:
Include signatures, dates, and
professional credentials
Be brief but descriptive
Individualize and tailor wording
to the specific needs of the
patient is key
Use progress notes to update
any changes to initial
service recommendations
W
h
i
l
e
g
u
i
d
e
l
i
n
e
s
f
o
r
d
o
c
u
m
e
n
t
a
t
i
o
n
v
a
r
y
a
c
r
o
s
s
s
t
a
t
e
s
,
a
g
e
n
c
i
e
s
a
n
d
p
r
o
v
i
d
e
r
t
y
p
e
s
,
a
n
d
w
i
l
l
d
i
f
f
e
r
a
c
c
o
r
d
i
n
g
t
o
s
t
a
n
d
a
r
d
s
r
e
l
a
t
e
d
t
o
s
p
e
c
i
f
i
c
n
e
e
d
s
—
m
o
s
t
i
n
c
l
u
d
e
:
1.
A clear concise statement of the presenting
problem, the history of the present illness, the
diagnosis, and current assessment and status
2.
A rationale for why services are necessary
(what risks will likely occur if not treated)
3.
A description indicating how the services
offered will be sufficient in amount, duration,
and type to achieve the purpose or goals
Insurance will deny
coverage if necessity
is not well documented
References
1.
Lorig, K. (2001).
Patient education: A practical approach.
Thousand
Oaks, CA: Sage Publications, Inc.
2.
Wagner, EH. (1998) Chronic disease management: What will it take to
improve care for chronic
illness? Effective Clinical Practice. 1: 2-4.
3.
Adams, N. & Grieder, D. (2005).
Treatment planning for person-centered
care.
Amsterdam: Elsevier Academic Press.
4.
Aquilino, A., DeBonis, J. A., Mola, E., Musilli, A., Panfilo, M., Rollo.R.
(2009, October). Project Leonardo: Final report of a study to evaluate the
feasibility and effectiveness of a model of
disease and care management
in the primary healthcare system for the management of patients
with
chronic conditions.
Il Sole 24 Ore,
Special Health (Sanita`) Supplement,
Pp. 3-66.
5.
Wagner, EH. (2000). The role of patient care teams in chronic disease
management.
BMJ, 320
(February), 569-572.
References
6.
Lorig K. Living a healthy life with chronic conditions: self-management of
heart disease, arthritis, diabetes, asthma, bronchitis, emphysema &
others. 3rd ed. Boulder, CO: Bull, 2006.
7.
Shared Decision-Making in Mental Health Care: Practice, Research, and
Future Directions. HHS Publication No. SMA-09-4371. U.S. Department
of Health and Human Services. Substance Abuse and Mental Health
Services Administration.
8.
Prochaska, J .O., Norcross, J. C., DiClemente, C. C. (1994).
Changing for
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Recognize the importance of the care planning process in Integrated Health, understand the differences between treatment plans, care plans, and action plans, and view care planning as a dynamic process involving ongoing updates and evaluation. Explore the traditional medical model versus newer patient-centered chronic care models, and learn how treatment planning has evolved from a bureaucratic exercise to a personalized, creative process. Discover the significance of treatment plans, care plans, and action plans in enhancing patient outcomes and promoting collaboration between healthcare providers and patients.
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Care Planning and Documentation in Integrated Health Module 10 Judith Anne DeBonis PhD Department of Social Work California State University Northridge
Module 10: Care Planning and Documentation in Integrated Health By the end of this module students will: Recognize the importance of the care planning process in IH Understand the differences between treatment plans, care plans, and action plans View the care planning process as an opportunity for creativity, discovery, and learning for both the patient and the provider Match and use empowering techniques in the implementation of a shared decision-making care planning process Acquire and utilize skills to enhance patient goals setting View care planning as a dynamic process involving ongoing updates and evaluation
Traditional Medical Model1 An individual s health plan and actions could be summed up as following the Doctor s orders
Newer Patient Centered Chronic Care Models 2 Today Patients are expected to be: 1. Informed The recipient of services must be the driving force in the development of a plan that articulates a vision of recovery 3 2. Proactive 3. Participate as a partner
Treatment Planning 3 Today, an alternative perspective Historically, a bureaucratic hurdle A time-consuming paper exercise performed to meet administrative or accreditation requirements. A learning experience between the patient and provider Accurate understanding of the individual needs, strengths, goals discovered through the alliance Disconnected, inconsequential with respect to what really happens in treatment Little to no impact on outcome. Not just filling in forms the new plans are informed, individualized, and built from creative thinking A roadmap that shapes and forms both the process and the product of treatment
Treatment Plans, Care Plans, Action Plans 4 Documents produced from the treatment planning process differ widely in definition and purpose 1. Treatment Plan Doctor s orders and recommendations with regard to the patient s medical care 2. Care Plan Based on the doctor s orders, the plan that the care manager and patient design in collaboration with the health team 3. Action Plan That portion of the care plan that the patient will implement at home. Contains individualized instructions that the patient has collaborated to develop. The care plan, created collaboratively by the health team, bridges the doctor s orders and the patient s personal goals Formal written plans can help to organize the work of teams and help patients to navigate the complexities of multidisciplinary care. 5
Individualizing the Care Plan 4 The Health Team The patient is considered the most important member of the health team Nurse Care Manager Specialists, Hospitals, other Healthcare Providers Care Plan Doctor/GP Patient
Both Patient & Provider Expertise Needed 6 Patients are the expert on their life Healthcare professionals are the expert on health practices What is important to me What I am willing to do What health actions I take For the patient, information may not be enough skills and confidence are also needed to participate fully.
Developing a Care Plan Using Shared Decision Making
Shared Decision Making (SDM) 7 Definition An interactive, collaborative process between providers and consumers that is used to make healthcare decisions in which at least 2 individuals work together as partners with mutual expertise to exchange information and clarify values in relation to options and thereby arrive at a discrete decision. GOAL Partnership A person-centered, supportive encounter which promotes the ideal conditions for effective decision making to occur Practitioner as a consultant to the consumer Helping to provide information Consumers are empowered with information so that their autonomy or control over healthcare decision making is increased To discuss options To clarify values and preferences To support consumer autonomy
How SDM Supports Patient Empowerment and Participation 7 In the shared decision-making process, practitioners are encouraged to think about and apply: 1. Self-directed care 2. Self-determination 3. Person-centered planning For consumers to participate fully as partners in a shared decision making process, they will need to information, skills, and confidence
Steps in a Shared Decision Making Process 7 1. Recognition that a decision needs to be made 2. Identification of the partners in the process as equals 3. Statement of options as equal 4. Exchange of information on pros and cons of options 5. Exploration of understanding and expectations 6. Identifying preferences 7. Negotiating options and concordance 8. Sharing the decision 9. Arranging follow-up to evaluate decision making outcomes
Matching Techniques and Approaches to the Shared Decision Making Process 1 Recognition that a decision needs to be made 7 Stage of Change 8 Empowerment 6 Solution-Focused 9 In contemplation: aware of the problem, but ambivalent about making a change How important do you think it is to others family, friends, doctor that you consider making these changes for your health? Identification of something YOU (the patient) want to accomplish or a problem that you want to resolve Decide what the person wants instead of what they don t want when what the person is doing is not working, have him or her do something different.
Matching Techniques and Approaches Identification of the partners in the process as equals 7 2 Stage of Change 8,11 Empowerment 6 Solution-Focused 9, 10 Providers respect the particular needs of persons in various stages and adjust their stance (nurturing parent, Socratic teacher, coach, consultant) to support specific actions necessary for the person to progress to the next stage Amplify and build on strengths to promote change in areas identified by the person and the view he/she holds for wanting things to be different Persons are allowed to direct their own course, focusing on one or two items that fit their interest or need This process will generate feelings of self efficacy, competence and build confidence Practitioners and patients construct the solutions together sometimes inventing them
Matching Techniques and Approaches Statement of options as equal 7 3 Stage of Change 8 Empowerment 6 Solution-Focused 9 Brainstorming offers multiple ideas for discovering new and creative possibilities. There are no right or wrong responses. All ideas are accepted and believed to hold potential. There are always solutions Each person will weigh a personalized set of pros and cons, choose from a variety of change processes, and choose among strategies for combating specific temptations There are more than one solution
Matching Techniques and Approaches Exchange of information on pros and cons of options 7 4 Stage of Change 8 Empowerment 6 Solution-Focused 9 Supporting the accumulation of personal reasons and benefits of change (pros) is necessary to shift the decisional balance from the costs of change (cons) Based on ideas generated from a brainstorm do any of the options seem workable for an individual s problems? Explore those options in detail. Exceptions for every problem exist and once discovered can be used to build a solution and a different view Helping the person to select the changes that will help them become more of what they like and want to see continue
Matching Techniques and Approaches Exploration of understanding and expectations 7 5 Stage of Change 8 Empowerment 6 Solution-Focused 9 In preparation, taking time to explore options and experiment can support individuals to choose a plan Setting goals that are small enough to be accomplished in one week is usually a reasonable expectation What will the change look like? How will things be different? Examining the details about how the change will feel, what will be noticed first when it occurs? Persons must have at least 70% confidence that they can accomplish the goal in 1 week an indication that the goal is reasonable and success is likely Understanding relapse is part of the process of change can encourage use of prevention tools
Matching Techniques and Approaches Identifying preferences 7 6 Stage of Change 8 Empowerment 6 Solution-Focused 9, 10 Deciding when to change, choosing the plan, the best tools and support for coping with setbacks, all is based on individual preferences Goals and actions taken to accomplish them are person-specific; there are many different paths and strategies that can be successful Instead what would you rather have? How will you be doing this? As you leave here today and you re on track, what will you be doing different or saying different to yourself?
Matching Techniques and Approaches Negotiating options and concordance 7 7 Stage of Change 8 Empowerment 1, 6 Solution-Focused 9,10 In all stages, change processes putting the focus on either thinking/feeling or behavior/doing are optional techniques to be applied to the process in agreement with the goals of the stage. Lower confidence levels can indicate that the goal should be renegotiated to a smaller step which has a greater change to be successful. Small changes lead to larger changes facilitates an easier way and simpler path to change What will make it worthwhile that you spent this hour here? Look for teachable moments where there is more openness to new information.
Matching Techniques and Approaches Sharing the decision 7 8 Stage of Change 8 Empowerment 1, 6 Solution-Focused 9 Solidifying the commitment to change often means sharing a plan with support network Tell people about your goals so they can provide support What would others say about the benefits of this change for you? The best feedback can come from others who also are managing a chronic condition How have you been able to decide this? At each stage decisions are made to take actions that can progress the person to the next stage. How will your change effect others?
Matching Techniques and Approaches Arranging follow-up to evaluate decision making outcomes 7 9 Stage of Change8, 11 Empowerment 6 Solution-Focused 9 In action consultant helps to monitor progress; offers a boost when progress is stalled and supports design of relapse prevention plan If something is not working, do something different. Review goal progress in 1 week; if successful, continue. Build on exceptions to the problems. Amplify small successes. Use brainstorming and problem-solving for discovering alternatives Miracle question response provides a detailed view of the change with specific indicators to watch for and reinforce. In maintenance preventing relapse, sustaining new behavior still requires commitment, energy.
Creating Client-Centered Goals that Reflect the Client s Desires
Lorig Three Empowering Techniques 6 Action Planning A way to turn a goal that you want to accomplish into a specific plan with steps Brainstorming A non-threatening way to generate a list of new ideas Problem Solving A process of self discovery and active engagement to explore options that lead to success
Action Planning 6 A Successful Action Plan turns goals into doable steps Is something YOU want to do Is reasonably accomplished in 1 week Is behavior-specific Answers: What? How much? When? How often? Begins with your confidence level at 7 or more (otherwise, renegotiate) Losing weight is not a behavior - not eating after dinner is
Value of Setting Goals 3 There is perhaps no greater expression of respect, understanding, hope, and empathy by the provider than the ability to elicit, acknowledge, and accept the individual and family goals 3 Patients who identify and bring personal goals to the attention of healthcare providers can: Receive support, encouragement, a sense of hope 1 Understand what specific results can be expected from treatments 2 Feel more motivated to participate in decision-making about their health 3
Solution-Focused Techniques For Well-Defined Goals: 10 Contributions 9 Helps identify strengths to be built upon Promotes expectation that small changes will lead to bigger changes Instills hope that change is possible Empowers changers Give a positive statement what the person will be doing or thinking rather than what they will not be doing or thinking Work with the person to describe specifically (in concrete terms)what the process will look like. Can you tell me more specifically how you will be doing that? What will you be doing when that happens? Use the person s words and language.
Solutions are a Type of Goal 9,10 Step 1 Define what the client wants rather than what he or she doesn t 3 Step 2 Look for what is working and do more of it 2 Step 3If what the client is doing is not working, have him or her do something different 1
SMART and Specific Using Smart Goals to Specify Objectives 3 S M A R T small pecific changes with a big impact easurable ttainable ealistic imely
Rewards as Part of Goal Setting Personalizing Rewards to Enhance Motivation 6 The real reward is a fuller and healthier life Self-reward frequently Add enjoyment to life it s part of the goal Give yourself some time off Do something 3 times a week for 10 minutes rather than every day Write down the goal tell others Note progress weekly Examples Deciding not to read the paper until after exercising Buying only 2 pieces of a favorite fruit at a time and walk the mile to the market each day for more Using money saved from not buying cigarettes to buy yourself something Remember that Olympic swimmers improved their race time when they rested in between their strenuous training and workouts!
Action Planning - Activity Making an Action Plan What are the typical goals set by consumers as part of their work with you? What do we do if a person has no goal? Using Lorig s ideas for successful Action Planning, how would you examine the goal and describe: How it fits the Lorig model How would it need to be adjusted Was the consumer successful? How does the Lorig model help when the person has no goal? The goal can be anything!
Brainstorming 6 Provide direction Step 1 What are some of the reasons people don t take medications as prescribed by their doctors? State the question to be brainstormed Step 2 Step 3 Write down every idea there are no right or wrong answers Step 4 Ask questions to clarify meaning Step 5 Use the ideas to summarize a point, begin a problem solving session, or create an action plan
Brainstorming - Activity Role Play Using Brainstorming Actions Generate a question Problem Someone you ve worked with is struggling with an obstacle to changing their behavior. Share ideas through brainstorming Dialogue to determine if any of the ideas might be used to help You and the person are at a loss as to how to proceed Make an action plan
Problem Solving 6 Step 1 Identify the problem or barrier Step 2 List ideas for solving the problem (from the brainstorm list) Step 3 Select one method to try In this process, identifying the problem or the barrier is the most difficult and most important! Step 4 Assess the results Step 5 Substitute another idea (if the first didn t work) Step 6 Use other resources Step 7 Accept that the problem may not be solvable now
Problem Solving - Activity Problem Solving Let s discuss How do you help them to put their goals into the SMART format? Think of some of the consumers you have spoken to What are some of the common goals they want to accomplish? How often do consumers set their goal as a series of small steps? Do you encourage setting up a reward plan? What would you imagine the person would answer: How will you know when it s time to make a change? What do you imagine will happen if you continue on as you are?
Integrating Other Providers in the Shared Planning and Decision-Making Process
Team Role in Treatment Planning3 A part of the commitment to person-centered care is attending to the process of developing, documenting and implementing an individual plan 3 The provider role is no longer all-knowing caregiver, but instead coach, architect, cheerleader, facilitator, and shepherd. 3 The plan is the glue that holds the team together and supports its success coordination is essential 1 2 The team is a group of people all working toward a common goal developing a plan that responds to the unique needs and desires of an individual and family 3 Both the team and the plan will need to be adaptable to change as the planning of care is a dynamic process
Engaging Families and Significant Others in the Care Planning Process
Involvement of Family and Friends 3 The family is a vital source of information and knowledge about the individual, their history, and needs, the role of culture in their lives, and other important details. Also, physical and emotional support of family can be a critical component of each individual's recovery 3 Serve as a reminder of history, which while painful, might communicate a message of hope about earlier goals 1 Respect for the individual and family/friends is essential; each is offered choice about the most comfortable way to participate and their preferences are accepted 2 May need to process past experiences and feelings, both good and bad, with regard to seeking treatment 3
Writing Effective and Concise Documentation
Documentation and Communication 12 Timely and concise information exchange enhances collaboration Communication between all providers is most effective and efficient when it is readily available, referred to and utilized with the consumer. Electronic Medical Records 13 Complex Considerations: 12 Record individual status and progress while also allowing for population dashboard data for decision support around key areas of interest: Allow multiple professionals to enter and access information Can be used to track behaviors, goals, progress and as timed reminders to ensure guideline care Offer educational and resources related materials for staff /consumers For metrics and measurements to be used effectively, information and data need to be collected, stored, easily accessed and presentable to those who will access them. Record policies, development of electronic health records and communication about data all need to be addressed Computer competence is an essential skill for social workers in IH
Whats your note preference? PIE, DAP, or SOAP? 4 Formats to help with writing a clear and concise progress note Problem identification, Intervention, Evaluation PIE Description, Assessment, Plan DAP SOAP Subjective, Objective, Assessment, Plan All structured and all require assessment as part of the note Well written notes in Integrated Health are SHORT and TO THE POINT! Can problem-oriented notes be used effectively to support an objective-oriented and recovery-oriented record?
Benefits of Well Written Notes Including a mini assessment is beneficial in that it keeps all providers clear and focused on the individual needs and desires of the consumer 3 A Win-Win 3 Medical records tell the story of a person and any reader should come away with an better understanding With good documentation it is more difficult to provide ineffective services for an extended period of time. The lack of progress becomes obvious to everyone and the provider and team will re-evaluate If service is effective, that too will be obvious and the enthusiasm will generate support and additional forward motion
Ongoing monitoring, reviewing and re-evaluation of goals 3 Assessment and reassessment allows for information gathering which can help to evaluate and monitor progress, modify and update the plan as needed Periodic review of the treatment plan: 1. Keeps the plan accurate and up-to-date 2. Helps maximize benefit from treatment interventions by determining what is working and what needs adjustment May uncover other barriers to treatment success that have not been identified Review may: Highlight areas of strength that can be used to increase positive outcomes in other less successful aspects of treatment Offer an opportunity to brainstorm about areas that are problematic and make choices for next steps
Considering Medical Necessity Standards and Requirements
Administrative Requirements 3 What services and where services are provided and at what level of care 5 Components of Medical Necessity: 3 1. Indicated where there is a diagnosis 2. Appropriate match between service and need 3. Efficacious likelihood that interventions or services will be effective Discussion Point: How can medical necessity requirements protect and help consumers and families? 4. Effective determining the impact and value of services provided 5. Efficient when services are appropriate, efficacious, and effective In what ways might these requirements be inappropriately applied and cause denial of services?
Documenting Medical Necessity Insurance will deny coverage if necessity is not well documented While guidelines for documentation vary across states, agencies and provider types, and will differ according to standards related to specific needs most include: Don t Forget: 1. A clear concise statement of the presenting problem, the history of the present illness, the diagnosis, and current assessment and status Include signatures, dates, and professional credentials Be brief but descriptive 2. A rationale for why services are necessary (what risks will likely occur if not treated) Individualize and tailor wording to the specific needs of the patient is key 3. A description indicating how the services offered will be sufficient in amount, duration, and type to achieve the purpose or goals Use progress notes to update any changes to initial service recommendations
References 1. Lorig, K. (2001). Patient education: A practical approach. Thousand Oaks, CA: Sage Publications, Inc. 2. Wagner, EH. (1998) Chronic disease management: What will it take to improve care for chronic illness? Effective Clinical Practice. 1: 2-4. 3. Adams, N. & Grieder, D. (2005). Treatment planning for person-centered care. Amsterdam: Elsevier Academic Press. 4. Aquilino, A., DeBonis, J. A., Mola, E., Musilli, A., Panfilo, M., Rollo.R. (2009, October). Project Leonardo: Final report of a study to evaluate the feasibility and effectiveness of a model of disease and care management in the primary healthcare system for the management of patients chronic conditions. Il Sole 24 Ore, Special Health (Sanita`) Supplement, Pp. 3-66. 5. Wagner, EH. (2000). The role of patient care teams in chronic disease management. BMJ, 320 (February), 569-572. with
References 6. Lorig K. Living a healthy life with chronic conditions: self-management of heart disease, arthritis, diabetes, asthma, bronchitis, emphysema & others. 3rd ed. Boulder, CO: Bull, 2006. 7. Shared Decision-Making in Mental Health Care: Practice, Research, and Future Directions. HHS Publication No. SMA-09-4371. U.S. Department of Health and Human Services. Substance Abuse and Mental Health Services Administration. 8. Prochaska, J .O., Norcross, J. C., DiClemente, C. C. (1994). Changing for good: A revolutionary six-stage program for overcoming bad habits and moving your life positively forward. New York: Avon Books. 9. DeJong, P., & Berg, I. K. (2007). Interviewing for solutions. Pacific Grove, CA: Brooks/Cole Publishing Company. 10.Walter, J. L., & Peller, J. E. (1992). Becoming solution-focused in brief therapy. New York: Brunner Routledge.
