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IR&RC Addiction Counselor Exam > Domain II - Treatment Planning, Collaboration, and referral > Flashcards

Domain II - Treatment Planning, Collaboration, and referral Flashcards

1
Q

What is treatment planning in regards to counseling?

A

The road map

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2
Q

What is intake?

A

Process of enrolling a client in a specific course of treatment for a substance use problem

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3
Q

What sort of process is intake?

A

Administrative

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4
Q

What is considered an extension of the screening process after referral is made?

A

Intake

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5
Q

What is orientation?

A

A process which describes the nature and goals of a substance us program to the client and family.

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6
Q

When are rules governing client conduct and consequences for violating said rules explained?

A

Orientation

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7
Q

When are the hours of operation, costs, terms of payment, and rights/responsibilities explained?

A

Orientation

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8
Q

What are the four basic functions of the intake process?

A

1) Establish eligibility; 2) Complete basic data; 3) Identify barriers and assets 4) Establish a treatment or service approach

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9
Q

How should the Intake process be arranged for different clients?

A

Should be standardized and consistent

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10
Q

Where can a counselor find a client’s rights in some states?

A

Administrative law or statutes for the profession

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11
Q

What is the right to individual dignity?

A

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

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12
Q

What does Habeas Corpus mean in regards to clients involuntarily committed?

A

They have the right to be told why they’re being kept and what evidence the court has to detain them

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13
Q

How are changes listed on the treatment plan?

A

Achievable goals

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14
Q

When goals are listed, what needs to be included with them?

A

What interventions and counseling methods will be used for each goal and how each goal will be measured for success

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15
Q

Aside from goals, measures, and interventions, what else should the treatment plan include?

A

Strengths, needs, abilities, and preferences

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16
Q

What is the treatment plan?

A

A contract between counselor and client

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17
Q

What needs to happen before making a treatment plan?

A

Assessment and diagnosis

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18
Q

How are the achievable goals selected?

A

Assess and prioritize the client’s needs based on urgency, motivation to change, and real-world influences on client’s needs

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19
Q

How is the level of care determined?

A

Evaluation of the diagnosis, strengths, and assets.

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20
Q

How do counselors make sure the treatment plan can be regularly reviewed?

A

Ongoing assessment and collaboration with the client

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21
Q

What should the treatment plan allow for?

A

Flexibility and changes

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22
Q

At a minimum, when should the treatment plan be reviewed?

A

Major points during treatment (intake, transfer, discharge, etc)

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23
Q

In what document is the frequency and duration of services noted?

A

Treatment plan

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24
Q

What does the counselor need to recognize while developing a treatment plan?

A

Different settings in which treatment takes place (residential vs outpatient) and that much of recovery is outside of treatment

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25
Q

How can the treatment plan address treatment more managably?

A

Divide treatment into phases

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26
Q

What phases may the treatment plan be broken into?

A

Engagement, stabilization, primary treatment, continuing care (aftercare)

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27
Q

How can the client be involved in the treatment planning process?

A

Help in prioritizing problems, selecting goals and objectives, and signing off on the treatment plan

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28
Q

How can information be shared within an organization?

A

On a need-to-know basis

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29
Q

What should be done if a client does not improve or fails to improve?

A

Re-evaluation of the program or level of care during the re-assessment of the treatment plan

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30
Q

What improves retention in regards to treatment planning?

A

Matching services to a client’s problems

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31
Q

Why is the treatment plan important for stakeholders and 3rd party payors?

A

Establishes accountability

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32
Q

How else can the treatment plan assist counselors?

A

Responding to legal/ethical challenges

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33
Q

What are the 4 key elements of the initial treatment plan?

A

Presenting problems; preliminary goals and objectives; type, frequency, and duration of service; signature and date of the client and counselor

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34
Q

When is the individualized treatment plan developed?

A

After the preliminary treatment plan has been reviewed, and agreement between counselor, client, and other parties has been reached.

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35
Q

What are key things on an individualized treatment plan in addition to those on the initial treatment plan?

A

Strengths, strategies, and diagnosis

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36
Q

To whom is the transtheoretical stages of change model attributed?

A

Procheska and DiClemente

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37
Q

What realms does service coordination and collaboration of services entail?

A

Administrative, clinical, and evaluative services

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38
Q

Who is included in service coordination/collaboration?

A

Client, treatment services, community agencies, and other resources

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39
Q

How does service coordination assist in the treatment plan?

A

Builds a framework of action, enabling the client to achieve specific goals

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40
Q

Why is service coordination necessary?

A

Client’s may have many other problems, such as HIV or psychiatric problems which need care

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41
Q

What are two key components of service coordination?

A

Case management and advocacy

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42
Q

How can service coordination help establishing realistic expectations?

A

Understanding the services, costs, and other important information about an organization

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43
Q

What is the biggest challenge to collaboration?

A

Each organization may wish to use a different assessment tool

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44
Q

What does the use of multiple assessment tools result in?

A

Fragmented pictures of clients, or at worst, the client becoming frustrated and leaving treatment

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45
Q

How can collaboration with other service providers help build a complete picture of a client?

A

Gather different viewpoints from other people who are experts in other areas.

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46
Q

How can fragmentation of information by service coordination be avoided?

A

Identify a primary contact for the cleint and other agencies which then completes a holistic assessment which will follow client throughout his referral process

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47
Q

On what levels can barriers to collaboration occur?

A

Personal, professional, and organization

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48
Q

How do personal attributes create barriers to coordination?

A

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

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49
Q

How do professional factors create barriers to coordination?

A

Different professionals have different views of addictions, client’s, and the treatment process.

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50
Q

How do organizational factors create barriers to coordination?

A

Recognizing the need for partnership and developing a shared mission

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51
Q

What is the purpose of case management?

A

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

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52
Q

What are the four mane objectives of case management?

A

1) Continuity of care; 2) accessibility; 3) accountability; and efficiency

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53
Q

How can case management assist in retention in CD treatment?

A

Remove barriers to treatment

54
Q

What is a core agency?

A

An organization with special coordinating power and authority

55
Q

How does case management assist in navigation of the health and social services system?

A

Provides a single point of contact rather than the client needing to coordinate with resources on their own.

56
Q

How is case management conducted?

A

Based on client needs and strengths

57
Q

Who takes the lead in case management?

A

The client.

58
Q

What is a main goal of case management when working with other organizations?

A

Advocate for the best interests of the client

59
Q

How should a counselor look at case management?

A

Pragmatically

60
Q

Why should case management be pragmatic?

A

Need to address basic needs so the client can meet higher level needs

61
Q

What should case management account for?

A

Cultural needs

62
Q

What are the prerequisites for good case management?

A

Establishing rapport quickly, setting boundaries, and being non-judgmental

63
Q

What things does a case manager need to be skilled with?

A

Understanding family, social, and community dynamics; understanding insurance; knowledge of diversity; and recognizing the need for an interdisciplinary approach

64
Q

What is the benefit of the referral process?

A

Facilitate the use of available support systems and community resources

65
Q

How can the referral process help ensure quality care?

A

Make sure client needs are being met by an appropriate resource.

66
Q

What does a counselor need to be familiar with in order to be effective with referrals?

A

Community and alcohol/drug resources

67
Q

When making a referral, what should the counselor do?

A

Explain the purpose of making a referral and familiarize them with the organization

68
Q

What is helpful when trying to locate resources?

A

Maintaining a database of community resources

69
Q

Why are referrals necessary?

A

Not all agencies provide the same services (example, a CD treatment facility may not provide medical treatment, but this is something many clients need.)

70
Q

What is important ethically when coordinating with referrals?

A

Knowing the limits of confidentiality and obtaining a release of information when necessary

71
Q

What can result when making referrals sometimes?

A

Negative experiences

72
Q

How can a counselor reduce the likelihood of a negative experience?

A

Setting realistic expectations.

73
Q

What is a comprehensive service plan?

A

A plan regarding the referrals and services to which a client has been referred./

74
Q

What are the three components of a comprehensive service plan?

A

Long term goals; current status narrative; required services, supports and resources

75
Q

What are the two roles of a case manager when working with a team of resources?

A

Facilitator and advocate

76
Q

How can the outcomes of case management be measured?

A

Client satisfaction; client outcomes; and service system

77
Q

What is the general purpose of documentation?

A

Communicate with other professionals about client care, and legal and administrative services

78
Q

What is important about documentation with 3rd party payors?

A

Making sure the documentation is accurate but meets the standards of the third party

79
Q

What is the primary purpose of documentation?

A

Records professional work

80
Q

How does documentation aid in supervision?

A

Provides the supervisor information about sessions when unable to directly observe

81
Q

How does documentation assist a client’s care within an organization?

A

Provides a longitudinal record of clinical information

82
Q

How does documentation assist with risk management?

A

Good documentation protects against malpractice lawsuits and professional discipline complaints

83
Q

What requirements does documentation need to meet?

A

Federal and state laws, regulations and rules; specific accreditation program requirements; and third party payer requirements

84
Q

What federal law manages drug and alcohol information in a client’s record?

A

Title 42 CFR, part 2

85
Q

What two laws must client records comply with?

A

HIPPA and 42 CFR

86
Q

How should information be shared within an agency?

A

On a need to know basis

87
Q

What rights does the client have in regard to access of their records?

A

They have the right to review their record and recieve copies of it.

88
Q

What are the HIPPA requirements for consent?

A

No consent is necessary to share information for treatment, payment, and healthcare operations except for therapy notes

89
Q

How long are medical records retained?

A

7 years

90
Q

What rule manages the disposal of records?

A

42 CFR

91
Q

How should client records be stored?

A

In a locked file cabinet protected from unauthorized access.

92
Q

What is screening documentation?

A

Documentation of the initial contact with a client

93
Q

What is the purpose of screening documents?

A

Gather and document preliminary information determining the client’s need for services, and appropriate level of care.

94
Q

What are key elements of the screening documents?

A

Referral source; presenting problems and acuity; background information; emotional/mental status; Client strengths and preferences; recommendation for assessment and other referral

95
Q

What is the purpose of intervention documentation?

A

Documents the activities and stratagies of treatment

96
Q

What sort of documents are included in intervention documentation?

A

Informed consent, ROIs, and SU tests; Intervention plans; summary of progress notes; copies of correspondence or reports; transfer or discharge summary

97
Q

What is the function of treatment documentation?

A

Document treatment activities and strategies

98
Q

What types of treatment documentation are there?

A

Administrative, medical, and clinical

99
Q

What is the function of progress notes?

A

Document the client’s progress in relation to treatment goals and objectives

100
Q

What is the function of the discharge summary?

A

Summarize services delivered, accomplishment of goals, and recommendations post discharge

101
Q

When should the discharge summary be started?

A

Intake

102
Q

What are main parts of a discharge summary?

A

Referral source; presenting problem; treatment goals, methods and outcomes; condition at discharge; follow up recommendations; signature

103
Q

What does EHR stand for?

A

Electronic health record

104
Q

How does the creation of EHR assist in treatment?

A

Tracks data over time; tracks progress of those who leave treatment; monitor and improve overall quality of care

105
Q

What does HIT stand for?

A

Health information technology

106
Q

Clinical documentation ensures what?

A

Accountability

107
Q

Why should information be presented in a way to ensure quality service?

A

A record may follow the client through the course of treatment and to other agencies.

108
Q

Why is it important to accurately represent the client?

A

Ensure quality care as the documentation passes down the line

109
Q

How should you write documents?

A

With the idea that others will read it

110
Q

Documentation should be written in an _______ manner.

A

Objective

111
Q

How should client actions be described?

A

As behaviors (example, Johnny did not talk in group vs Johnny was resistant)

112
Q

What should be avoided in documentation?

A

Jargon such as acronyms and technical terms

113
Q

How can counselors write documents in a way that documents the session but isn’t time consuming?

A

Keep it simple and concise

114
Q

In what light should the client be represented in documentation?

A

In a positive manner

115
Q

What is true of all entries made by a clinician in a client record?

A

It needs to be signed and dated with credentials

116
Q

What is true of the date on records?

A

It should be dated the day it is written, not the day activities occur

117
Q

If documentation is written on a date different than the events, what should be noted?

A

The date on which the interaction occurred

118
Q

What should happen if information is added to a document after the fact?

A

It should be notated with “late entry” or “correction”

119
Q

What should happen if an error is made on paper documents?

A

Cross it out, initial it, and mark it with “error”

120
Q

What is the the benefit of recovery planning?

A

Abstinence and symptom reduction; Improved psychological/physical health; and better social relationships

121
Q

What is the function of treatment goals?

A

Provide stabilization; meat established outcomes; increase resilience/reduce vulnerabilities in an effort to enhance recovery

122
Q

What is recovery?

A

A process of change through which an individual achieves abstinence

123
Q

What are benefits of recovery?

A

Improved health and wellness, and increased quality of life.

124
Q

What is the function of a recovery/wellness plan?

A

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

125
Q

On what has more recent emphasis been placed in regards to maintaining recovery?

A

Peer recovery support

126
Q

What is peer-based recovery support?

A

The process of giving and receiving support from those who are not professionally credentialed

127
Q

What are the goals of peer support?

A

Initiate recovery, maintain recovery, and enhance quality of life

128
Q

When is peer support initiated?

A

During or after treatment

129
Q

What can be helpful for those who do not wish to access formal treatment programs?

A

Peer support

130
Q

How do peer support specialists help maintain recovery?

A

Developing recovery skills, accessing resources, and giving individuals an opportunity to enrich recovery through volunteering

IR&RC Addiction Counselor Exam (6 decks)

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