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Treatment Planning and Reassessment
Dr. Dawn-Elise Snipes PhD, LPC-MHSP
Executive Director, AllCEUs
Objectives
– Review multiple ways of writing treatment plans including using the integrative summary, FARS, CANS, ASAM and LOCUS
– Review pitfalls in writing effective treatment plans and how to avoid them
– Review the purpose of the reassessment and best practices for documentation
– Identify time-effective methods for completing treatment plans and reassessments
Integrated Summary & Reassessment
– Purpose
– To summarize the person’s story (Executive Summary) for communication between providers
– To synthesize information to support the diagnosis and level of care
– Drive the treatment plan by identifying
– What the problems are (as evidenced by)
– How they are impacting the patient
– How we are attending to their physical, social, emotional and behavioral needs
Parts of the IS & Reassessment
– A summary of the presenting problem and evidence of impairments
– The person’s diagnosis and evidence
– Recommendations for treatment and defense using ASAM, LOCUS or CANS guidelines
– Current focus of treatment and how the person’s current strengths and needs will be used
– What will be addressed
– Why will it be addressed
– How will it be addressed
– Family involvement (if any)
– Preliminary Relapse Prevention Plan
Writing Good ISs and Reassessments
– The IS and Reassessment are where you get to
– Summarize the facts
– State and support your subjective opinions
– Support your diagnosis
– Support your recommendations for treatment
– Identify initial treatment goals (with the patient)
– Develop a preliminary relapse prevention plan
– They should be a quick read that supports:
– What is wrong
– Why insurance should reimburse for this level of care
– How we are going to assist the patient in a meaningful way improve emotional, behavioral, social, and physical functioning.
Writing Good Ones…
– Read like a reviewer
– What is wrong-
– How is this impacting the person socially, emotionally, physically, occupationally-
– What is maintaining it-
– What strengths and supports are already there, and how can they be used-
– What level of care is recommended
– Why is this level needed
– What are the goals for this level of care
– How can we help the patient avoid a higher level of care-
Rubric for ISs & Reassessments
Pitfalls In Writing Effective Plans & Reassessments
– Failing to use objective, measurable goals
– Not getting client feedback and buy-in
– Failing to ask why the client might lose motivation for change
– Failure to reassess frequently enough and insufficient rewards
Purpose of Planning & Reassessment
– Planning
– Sets measurable & achievable targets
– Helps define the “whys” of interventions
– Increases efficacy through accomplishment
– Frequent Reassessment
– Identifies progress, hurdles and waning motivation
– Provides opportunities for rapid cycle change
Time Effective Documentation
– Get the client’s assistance
– At assessment provide a treatment planning worksheet (4 parts)
– Part 1
– What is important in my rich and meaningful life (people, things, activities)
– Which of those things do I currently have in my life-
Time Effective Documentation
– Part 2
– What problems am I currently having
– PACER Dimensions
– Physical: Health, nutrition, sleep, energy, medication, pain
– Affect: Depression, anxiety, guilt, grief, anger, mania
– Cognition: Attitude and perspective on life, thought process, rumination, negativity, concentration, self awareness, self-esteem, judgment/impulsivity
– Environment: Housing, environmental stressors (sights, smells, sounds, temperature, people, situations)
– Relationships: Family, friends, interpersonal skills,
Time Effective Documentation
– Part 3
– Based on the assessment, what changes do I need to make- Rank them in order from most to least ready to change.
– Part 4
– For each problem identified answer the questions
– When I do not have this problem what is different-
– What can I start doing to address this issue-
Time Effective Documentation
– Get the client(s) to do it with you for empowerment
– Problem: Fatigue
– What will be different when my problem is resolved-
– I will be less fatigued as evidenced by not needing as much caffeine, feeling rested when I awaken in the morning and being able to stay up for 14-16 hours per day.
Reassessment
– Client worksheets (group/individual review sessions)
– Each person is given a copy of their treatment plan
– Reassessment Worksheet
– My goals for this week
– Goal 1: _________________ Accomplished- Yes No
– If no, identify obstacles: (motivation, resources, knowledge, new problems…)
– What changes may need to be made to your treatment plan to address obstacles-
Summary
– A good assessment and integrative summary forms the foundation of an effective treatment plan
– When clients participate, they are empowered and more motivated
– Assessment instruments like the FARS, CANS or LOCUS help the client and clinician identify and define the problems
– Reassessment activities help the client see progress, get support and make adjustments to promote rapid cycle change