Domain II - Treatment Planning, Collaboration, and referral Flashcards
What is treatment planning in regards to counseling?
The road map
What is intake?
Process of enrolling a client in a specific course of treatment for a substance use problem
What sort of process is intake?
Administrative
What is considered an extension of the screening process after referral is made?
Intake
What is orientation?
A process which describes the nature and goals of a substance us program to the client and family.
When are rules governing client conduct and consequences for violating said rules explained?
Orientation
When are the hours of operation, costs, terms of payment, and rights/responsibilities explained?
Orientation
What are the four basic functions of the intake process?
1) Establish eligibility; 2) Complete basic data; 3) Identify barriers and assets 4) Establish a treatment or service approach
How should the Intake process be arranged for different clients?
Should be standardized and consistent
Where can a counselor find a client’s rights in some states?
Administrative law or statutes for the profession
What is the right to individual dignity?
Clients are given personal freedoms and not detained against their will without good cause; right to participate in formulation of treatment plan; right to receive services in least restrictive/most appropriate setting
What does Habeas Corpus mean in regards to clients involuntarily committed?
They have the right to be told why they’re being kept and what evidence the court has to detain them
How are changes listed on the treatment plan?
Achievable goals
When goals are listed, what needs to be included with them?
What interventions and counseling methods will be used for each goal and how each goal will be measured for success
Aside from goals, measures, and interventions, what else should the treatment plan include?
Strengths, needs, abilities, and preferences
What is the treatment plan?
A contract between counselor and client
What needs to happen before making a treatment plan?
Assessment and diagnosis
How are the achievable goals selected?
Assess and prioritize the client’s needs based on urgency, motivation to change, and real-world influences on client’s needs
How is the level of care determined?
Evaluation of the diagnosis, strengths, and assets.
How do counselors make sure the treatment plan can be regularly reviewed?
Ongoing assessment and collaboration with the client
What should the treatment plan allow for?
Flexibility and changes
At a minimum, when should the treatment plan be reviewed?
Major points during treatment (intake, transfer, discharge, etc)
In what document is the frequency and duration of services noted?
Treatment plan
What does the counselor need to recognize while developing a treatment plan?
Different settings in which treatment takes place (residential vs outpatient) and that much of recovery is outside of treatment
How can the treatment plan address treatment more managably?
Divide treatment into phases
What phases may the treatment plan be broken into?
Engagement, stabilization, primary treatment, continuing care (aftercare)
How can the client be involved in the treatment planning process?
Help in prioritizing problems, selecting goals and objectives, and signing off on the treatment plan
How can information be shared within an organization?
On a need-to-know basis
What should be done if a client does not improve or fails to improve?
Re-evaluation of the program or level of care during the re-assessment of the treatment plan
What improves retention in regards to treatment planning?
Matching services to a client’s problems
Why is the treatment plan important for stakeholders and 3rd party payors?
Establishes accountability
How else can the treatment plan assist counselors?
Responding to legal/ethical challenges
What are the 4 key elements of the initial treatment plan?
Presenting problems; preliminary goals and objectives; type, frequency, and duration of service; signature and date of the client and counselor
When is the individualized treatment plan developed?
After the preliminary treatment plan has been reviewed, and agreement between counselor, client, and other parties has been reached.
What are key things on an individualized treatment plan in addition to those on the initial treatment plan?
Strengths, strategies, and diagnosis
To whom is the transtheoretical stages of change model attributed?
Procheska and DiClemente
What realms does service coordination and collaboration of services entail?
Administrative, clinical, and evaluative services
Who is included in service coordination/collaboration?
Client, treatment services, community agencies, and other resources
How does service coordination assist in the treatment plan?
Builds a framework of action, enabling the client to achieve specific goals
Why is service coordination necessary?
Client’s may have many other problems, such as HIV or psychiatric problems which need care
What are two key components of service coordination?
Case management and advocacy
How can service coordination help establishing realistic expectations?
Understanding the services, costs, and other important information about an organization
What is the biggest challenge to collaboration?
Each organization may wish to use a different assessment tool
What does the use of multiple assessment tools result in?
Fragmented pictures of clients, or at worst, the client becoming frustrated and leaving treatment
How can collaboration with other service providers help build a complete picture of a client?
Gather different viewpoints from other people who are experts in other areas.
How can fragmentation of information by service coordination be avoided?
Identify a primary contact for the cleint and other agencies which then completes a holistic assessment which will follow client throughout his referral process
On what levels can barriers to collaboration occur?
Personal, professional, and organization
How do personal attributes create barriers to coordination?
A practitioner may have certain perceptions of the world based on their own social and cultural identity which effects the ability to create mutual trust
How do professional factors create barriers to coordination?
Different professionals have different views of addictions, client’s, and the treatment process.
How do organizational factors create barriers to coordination?
Recognizing the need for partnership and developing a shared mission
What is the purpose of case management?
To help individuals identify needed services, select the most appropriate services available in a given georaphical area, facilitate linkage with services, and promote continued retention in CD treatment
What are the four mane objectives of case management?
1) Continuity of care; 2) accessibility; 3) accountability; and efficiency
How can case management assist in retention in CD treatment?
Remove barriers to treatment
What is a core agency?
An organization with special coordinating power and authority
How does case management assist in navigation of the health and social services system?
Provides a single point of contact rather than the client needing to coordinate with resources on their own.
How is case management conducted?
Based on client needs and strengths
Who takes the lead in case management?
The client.
What is a main goal of case management when working with other organizations?
Advocate for the best interests of the client
How should a counselor look at case management?
Pragmatically
Why should case management be pragmatic?
Need to address basic needs so the client can meet higher level needs
What should case management account for?
Cultural needs
What are the prerequisites for good case management?
Establishing rapport quickly, setting boundaries, and being non-judgmental
What things does a case manager need to be skilled with?
Understanding family, social, and community dynamics; understanding insurance; knowledge of diversity; and recognizing the need for an interdisciplinary approach
What is the benefit of the referral process?
Facilitate the use of available support systems and community resources
How can the referral process help ensure quality care?
Make sure client needs are being met by an appropriate resource.
What does a counselor need to be familiar with in order to be effective with referrals?
Community and alcohol/drug resources
When making a referral, what should the counselor do?
Explain the purpose of making a referral and familiarize them with the organization
What is helpful when trying to locate resources?
Maintaining a database of community resources
Why are referrals necessary?
Not all agencies provide the same services (example, a CD treatment facility may not provide medical treatment, but this is something many clients need.)
What is important ethically when coordinating with referrals?
Knowing the limits of confidentiality and obtaining a release of information when necessary
What can result when making referrals sometimes?
Negative experiences
How can a counselor reduce the likelihood of a negative experience?
Setting realistic expectations.
What is a comprehensive service plan?
A plan regarding the referrals and services to which a client has been referred./
What are the three components of a comprehensive service plan?
Long term goals; current status narrative; required services, supports and resources
What are the two roles of a case manager when working with a team of resources?
Facilitator and advocate
How can the outcomes of case management be measured?
Client satisfaction; client outcomes; and service system
What is the general purpose of documentation?
Communicate with other professionals about client care, and legal and administrative services
What is important about documentation with 3rd party payors?
Making sure the documentation is accurate but meets the standards of the third party
What is the primary purpose of documentation?
Records professional work
How does documentation aid in supervision?
Provides the supervisor information about sessions when unable to directly observe
How does documentation assist a client’s care within an organization?
Provides a longitudinal record of clinical information
How does documentation assist with risk management?
Good documentation protects against malpractice lawsuits and professional discipline complaints
What requirements does documentation need to meet?
Federal and state laws, regulations and rules; specific accreditation program requirements; and third party payer requirements
What federal law manages drug and alcohol information in a client’s record?
Title 42 CFR, part 2
What two laws must client records comply with?
HIPPA and 42 CFR
How should information be shared within an agency?
On a need to know basis
What rights does the client have in regard to access of their records?
They have the right to review their record and recieve copies of it.
What are the HIPPA requirements for consent?
No consent is necessary to share information for treatment, payment, and healthcare operations except for therapy notes
How long are medical records retained?
7 years
What rule manages the disposal of records?
42 CFR
How should client records be stored?
In a locked file cabinet protected from unauthorized access.
What is screening documentation?
Documentation of the initial contact with a client
What is the purpose of screening documents?
Gather and document preliminary information determining the client’s need for services, and appropriate level of care.
What are key elements of the screening documents?
Referral source; presenting problems and acuity; background information; emotional/mental status; Client strengths and preferences; recommendation for assessment and other referral
What is the purpose of intervention documentation?
Documents the activities and stratagies of treatment
What sort of documents are included in intervention documentation?
Informed consent, ROIs, and SU tests; Intervention plans; summary of progress notes; copies of correspondence or reports; transfer or discharge summary
What is the function of treatment documentation?
Document treatment activities and strategies
What types of treatment documentation are there?
Administrative, medical, and clinical
What is the function of progress notes?
Document the client’s progress in relation to treatment goals and objectives
What is the function of the discharge summary?
Summarize services delivered, accomplishment of goals, and recommendations post discharge
When should the discharge summary be started?
Intake
What are main parts of a discharge summary?
Referral source; presenting problem; treatment goals, methods and outcomes; condition at discharge; follow up recommendations; signature
What does EHR stand for?
Electronic health record
How does the creation of EHR assist in treatment?
Tracks data over time; tracks progress of those who leave treatment; monitor and improve overall quality of care
What does HIT stand for?
Health information technology
Clinical documentation ensures what?
Accountability
Why should information be presented in a way to ensure quality service?
A record may follow the client through the course of treatment and to other agencies.
Why is it important to accurately represent the client?
Ensure quality care as the documentation passes down the line
How should you write documents?
With the idea that others will read it
Documentation should be written in an _______ manner.
Objective
How should client actions be described?
As behaviors (example, Johnny did not talk in group vs Johnny was resistant)
What should be avoided in documentation?
Jargon such as acronyms and technical terms
How can counselors write documents in a way that documents the session but isn’t time consuming?
Keep it simple and concise
In what light should the client be represented in documentation?
In a positive manner
What is true of all entries made by a clinician in a client record?
It needs to be signed and dated with credentials
What is true of the date on records?
It should be dated the day it is written, not the day activities occur
If documentation is written on a date different than the events, what should be noted?
The date on which the interaction occurred
What should happen if information is added to a document after the fact?
It should be notated with “late entry” or “correction”
What should happen if an error is made on paper documents?
Cross it out, initial it, and mark it with “error”
What is the the benefit of recovery planning?
Abstinence and symptom reduction; Improved psychological/physical health; and better social relationships
What is the function of treatment goals?
Provide stabilization; meat established outcomes; increase resilience/reduce vulnerabilities in an effort to enhance recovery
What is recovery?
A process of change through which an individual achieves abstinence
What are benefits of recovery?
Improved health and wellness, and increased quality of life.
What is the function of a recovery/wellness plan?
Formulate recovery goals and objectives; facilitate linkages to support services and communities; establish markers to measure progress; create a backup plan for when things do not go well
On what has more recent emphasis been placed in regards to maintaining recovery?
Peer recovery support
What is peer-based recovery support?
The process of giving and receiving support from those who are not professionally credentialed
What are the goals of peer support?
Initiate recovery, maintain recovery, and enhance quality of life
When is peer support initiated?
During or after treatment
What can be helpful for those who do not wish to access formal treatment programs?
Peer support
How do peer support specialists help maintain recovery?
Developing recovery skills, accessing resources, and giving individuals an opportunity to enrich recovery through volunteering
