Outpatient Clinic Policy -- DHS 35

OUTPATIENT CLINIC POLICY -- DHS 35

May, 2010

 

DHS 35.123 Staffing requirements for clinic.

The clinic has an assigned "clinic administrator" who is responsible for clinic operations. The clinic also has two or more licensed treatment professionals who combined are available to provide outpatient mental health services at least 60 hours per week. (See clinic staff roster)

The clinic has one branch office. The clinic provides services to all age groups.

 

DHS 35.13 Personnel policies.

The clinic maintains personnel records on each staff person providing psychotherapy or prescribing medications that demonstrate their professional qualifications and competence. The personnel records shall contain an up-dated copy of their professional license, certifications, background checks, possible disciplinary actions, and any practice restrictions initiated by the clinic administrator. The clinic will also maintain an updated vita of work experience and training for each professional.

 

DHS 35.14 Clinical supervision and clinical collaboration.

A. Consumer outcomes rating system

The clinic will determine "the status and achievement" of consumer outcomes by developing a system for measuring progress of each individual served at the time of discharge from services, as to whether there was substantial improvement, moderate improvement, small improvement, or no improvement. This rating will be made by the professional who provided the services. The rating will be entered onto a form identified as Consumer Outcomes-Outpatient Clinic. This form will show the name of the consumer, date of birth, the date of entry into services, the date of discharge from services, the rating made, and a brief statement of reasons for that rating. The formed will be signed and dated by the professional making the rating, and countersigned by the supervisor. This form will placed in the consumer file, next to the discharge summary. This form will be blue. A copy of this form will be maintained in a file identified by year of discharge. At the end of the year the information will be collated and summarized in a written statement, showing overall clinic performance, and performance for each individual professional. This summary will be sent to the clinic administrator, the director of the agency, the business manager, and to the individual professionals involved.

 

B. Clinical supervision

The clinic administrator will provide supervision to staff who do psychotherapy, including licensed mental health professionals. The supervision will occur at regular intervals, as follows: Within 30 days of intake, every 90 days thereafter during the course of services, and within 30 days of discharge. Supervision will be face-to-face and will be provided for every consumer served. Supervision will occur more frequently than this if required by the supervisor or the clinic administrator. Supervision will also occur more frequently if the consumer is having a mental health crisis. The mental health professional providing services will identify risks with the supervisor, which may require a stepped-up schedule of supervision. The supervision will be documented in the individual record on a green form that identifies the name of the consumer, date of birth, date of admission, date of supervision, whether that supervision was for intake, review, or discharge, any risk factors, and a brief narrative summarizing status and recommendations. The supervisor will sign each entry in the supervision record.

Each provider of psychotherapy will maintain their own system for identifying when supervision is required within these timelines.

C. Clinical collaboration

This is optional and may be used in the clinic with the permission of the clinic administrator. Licensed or certified professionals providing psychotherapy may employ this option if the clinical supervisor is not available on a regularly scheduled review date, or if the mental health professionals prefer this option. The clinic administrator will review summaries of meetings employing the clinical collaboration method. The clinical collaboration meetings will be summarized on the same green form employed for clinical supervision, with a notation showing that this was clinical collaboration, the people who attended the meeting, and the narrative summary of findings and recommendations. The most advanced person in attendance will sign and date the supervision entry. The same timelines apply for this method as apply to clinical supervision. Also, the same concerns apply with identifying risk issues. The clinic administrator will be made aware of risks and how these are being addressed. The clinic administrator may attend any of these clinical collaboration meetings and may require additional supervision for any staff performing psychotherapy services, or additional supervision during a mental health crisis.

D. General supervision

The clinic administrator will supervise all staff of the clinic in the performance of their duties, including their effectiveness in their job functions, their accuracy and timeliness in completing paperwork, their caseload responsibilities, their commitment to ethics of their profession, as well as to ethics of the clinic, and their degree of adherence to clinic policy in their personal and professional conduct. From time to time, the clinic administrator will modify the work responsibilities of employees in the clinic, or contracted staff, adding to existing functions, taking away existing functions, or creating new ones, for the purpose of meeting clinical and administrative goals. Office support staff, psychiatry, psychotherapists, nurses, case managers, AODA staff, and crisis intervention staff all contribute to the operation of the clinic, and their contribution will be considered and assessed by the clinic administrator for the purpose of making the clinic as a whole function more effectively.

Some supervision will be formal and scheduled on a regular basis. Some supervision will involve periodic meetings with the supervisor for purposes of addressing the contribution of staff to clinic operations. Other supervision will be informal, identifying a need when it occurs, when a problem develops, or changes in clinic procedures become necessary. The interconnectedness of the unit as a whole allows the development of a unit culture. This group effect will encompass all staff, and produces most of the accountability influencing everyone in their contribution to daily operations. The clinic administrator will help set the tone and narrative which makes the unit a cohesive, functioning organization. The clinic administrator will perform this guidance role by tapping into the formal and informal communications occurring among staff members.

 

DHS 35.16 Admission

A. Screening

Primary services from the outpatient clinic include psychotherapy and/or psychotropic medication prescriptions. These services are offered at the office, through the appropriate mental health professional. These two services are formal outpatient clinic services. They each follow a body of practice guidelines in their delivery, with legal, ethical, fiscal, and effectiveness considerations being made for each person who applies for services. People who apply may not qualify for either of these services, even if they have a mental health problem. Thus, we will set up a screening procedure to identify those who are appropriate for these outpatient mental health services.

Ordinarily, people request services from the outpatient clinic themselves. They may request psychotherapy or medication therapy specifically, or they may just indicate that they are having problems and want to find out what is available to help them. Sometimes, neither psychotherapy or medication therapy is appropriate, although other mental health services may be helpful. Other services, such as crisis intervention, case management, outreach, community intervention, information and referral, or prevention may be provided by outpatient clinic staff, in some situations. Sometimes these other services will suffice, and formal admission to outpatient psychotherapy won’t be necessary. The screening process will identify individuals who are likely to benefit from outpatient psychotherapy services. Other people will be referred to a different service or will be advised to provide additional information before they can be admitted for outpatient psychotherapy or medication therapy.

These two services, outpatient psychotherapy and medication therapy, follow a formal process, for admission, ongoing services, and discharge. These two services are the primary objects examined through the lens of the clinic certification standards, DHS 35. The other services referenced above are ancillary clinic services. All clinics provide the ancillary services to some degree, but the public mental health clinics, especially, are reliant on these subsidiary activities.

 

Services from the clinic begin on the first contact, in a broad sense, but admission to a formal clinic program doesn’t occur until admission procedures have been completed, which may require one or more contacts. The time frame from the first point of contact to the point of admission to a program is the screening phase. During the screening phase, several things may occur:

1. The individual may be ruled out of services at the clinic.

2. A lesser service provided by the clinic may be offered, that is, a less formal service such as information and referral may suffice.

3. Emergency services may be offered.

4. Outreach services may be offered.

5. Consultation services may be offered to someone making a referral or to someone requesting services to clarify a concern and to secure access to the appropriate participants.

6. The clinic representative may put an application on hold until additional information is provided by the caller such as information on recent or current treatment obtained elsewhere, financial information, or basic information to clarify the nature of the problem, including who should participate. The individual making the contact will be informed that additional information is necessary before the screening can be completed, what information is required, and actions on the part of the caller necessary for obtaining that information.

7. The individual may be given an appointment to be interviewed by the program intake professional. This person will conduct a clinical interview with the consumer and will establish whether or not the requirements have been met for admission to the program. This interview is identified as the intake session, which is reviewed below.

An application for services may be rejected or put on hold if any of the following are true:

1. The adult seeking services is not the person contacting the clinic to set up an appointment.

2. A child contacts the clinic to seek services.

3. A parent refuses to accompany their child to the clinic for services.

4. An adult refuses to participate in the intake procedures, or in the interviews required to establish a treatment plan.

5. The person refuses to divulge financial information or insurance information.

6. The person applies for a sliding scale fee while they are a resident of a different county.

7. The person applying for services cannot identify a mental health problem.

8. The person applying for services indicates that they are requesting admission because they were ordered by the court to come in for services.

9. The person applying was advised by their attorney to come in due to a legal defense, or legal suit.

10. The person is unable to participate in services due to some physical infirmity.

11. The person has an established pattern of drug seeking.

12. The person has failed previous services due to an inability to keep appointments.

These are some examples, by no means totally inclusive, of situations which may not fit program requirements. If any of these occur, in the course of admitting someone to services, or in the screening process, the application for services may be terminated or put on hold until additional information is obtained, and the legally responsible party is participating in the admission process.

Terminating an application or putting an application on hold will result in providing the person with information about what other options are available and what additional information is necessary before the application can be completed. Sometimes, these matters can be cleared up through additional questions, or through contact with a different person. It is the obligation of the clinic to inform the applicant what is necessary to proceed.

These screenings will be conducted by phone interview or by face-to-face interview. The screener will be trained in conducting a structured interview for this purpose. The screener will complete a screening form, which will become a part of the mental health record. The clinic administrator will review these screenings to assist the screener in advising the caller or in obtaining more information, if necessary. The clinic administrator may interview the applicant, and possibly collaterals as well, if the screening process cannot be completed in the regular way, or, an intake professional will conduct a triage interview to determine whether a formal service or an ancillary service is necessary, a different kind of service not offered at the clinic is necessary, or no service at all is necessary.

The purpose of this screening process is to admit people to office-based services, i.e., psychotherapy or medication therapy, who have bona fide mental health problems rather than some other kind of problem. The screening allows the consumer an opportunity to state their mental health problem in their own words, and to state their reasons for seeking services from the clinic. The screening is also intended to identify those who are willing and able to participate in services provided in the office, who are legally responsible for themselves (or have a legal sponsor who participates), and who can offer their consent knowingly to the procedures entailed. People with mental health problems who cannot or will not do these things, may qualify for a different kind of mental health service, or none at all. People with bona fide mental health problems may be served better through other services than through office-based psychotherapy or medication therapy.

B. Initial appointment (Intake session)

The initial appointment in the outpatient clinic will be with a licensed (or certified) mental health professional. That professional will conduct an intake interview with the person, and will complete an initial assessment and treatment plan (in red) signed by the therapist and the consumer. The initial assessment and treatment plan will identify the major problems, in summary form, and will identify the primary goals of treatment and the primary methods. These initial assessments and treatment plans will be handwritten, on the spot, with the consumer present. The initial assessment and treatment plan will identify the primary diagnosis, and will identify the need for psychotherapy, or the need for medication therapy, or the need for other services, such as crisis intervention services, or medical services at a medical clinic. If other issues are apparent that require additional discussion or clarification those will be identified along with what steps will be taken to address an issue. If the therapist advises the consumer to do something before the next meeting, that recommendation will also be identified on the plan. If the individual needs to see the psychiatrist that will be entered on this document, or if they have an AODA issue. AODA problems with recommendations will be included (see below).

A new form (in red) will be devised for the purpose of summarizing the initial appointment meeting, which will be identified as "Initial Assessment and Treatment Plan." This form will be placed in the treatment record.

Ordinarily, the therapist will identify if further psychotherapy appointments are necessary. If they are this will be discussed with the consumer in the first session. The psychotherapist indicates that psychotherapy is "medically necessary" through the process of identifying the mental health problems and by the process of recommending more psychotherapy. However, a prescription for the psychotherapy must be placed in the chart, using the form for this purpose. If the person is a Medicaid recipient, a physician will be employed for this purpose of determining medical necessity of psychotherapy. Either a psychiatrist, or a primary care physician, can make this recommendation, using the psychotherapy prescription form. The physician prescription will be placed in the record. Ordinarily, it is helpful to involve the primary care physician in this process whenever possible as a means of promoting a team approach with medical professionals. As an optional method, any licensed mental health professional can prescribe psychotherapy for people not enrolled in Medicaid in lieu of using the physician. The licensed professional performing the intake session would then sign the prescription form.

 

C. Other intake documentation

The consumer will be informed of the procedure for filing a grievance and will be informed of their rights as a patient. On the initial meeting the consumer will be told what happens at a mental health clinic, what they are expected to do, what the mental health professional will do, and why. The consumer will be informed of the cost of the service, and how much out of pocket they will have to pay. The fee for services, whether billed to insurance, or billed on the sliding scale, any co-pays, or deductible amounts will have to be established before the second meeting. The consumer will sign a financial agreement form outlining these costs. The therapist will countersign the financial agreement form. The consumer will also be asked to sign a privacy notice required by HIPAA. The consumer will sign appropriate release of information forms at the first meeting.

The consumer must consent to further services beyond the first meeting, based on the information that is obtained in the first meeting and the recommendations that follow from it. At the end of this process of developing an initial assessment and plan, the consumer will be asked to sign this initial plan, authorizing additional appointments. Signing the initial assessment and plan will be done in concert with signing the consent for treatment and services, which references their rights as a patient, and signifies their willingness to proceed with services. All these steps will be completed in the first meeting.

A second meeting cannot occur without all of these activities being completed. All intake forms should be completed in the first meeting. The comprehensive assessment and plan do not have to be completed in the first meeting. These are typed and are added to the record later. The typed assessment and the typed treatment plan must be consistent with the initial assessment and treatment plan in broad outline. However, the typed documents will be more thorough and will develop the narrative more completely. The comprehensive assessment and treatment plan will be in a narrative format, not a checklist format.

By the time the first session is completed, the consumer will be registered in the program, or admitted to the program. The comprehensive intake summary and treatment plan, also known as the intake summary, will be typed and added to the treatment record later, before the meeting with the supervisor to review the new case.

Sometimes the outpatient staff will request records from a prior treatment facility before setting up another appointment with the individual. The person will be informed of such a request for records, and what impact that might have on services. If the therapist wants to directly contact a previous provider, the therapist will so inform the consumer.

All of the forms discussed above, which are required for building a treatment record for each individual consumer (the identified client), are listed in the appendix that follows.

D. Prescription for psychotherapy

The clinic may continue to employ the option of using a primary care physician or a psychiatrist to prescribe psychotherapy. In this instance, the clinic will obtain a written prescription from the physician and enter it into the treatment record.

Alternatively, the clinic may choose to have the psychotherapist (licensed only) at the time of intake complete a prescription for psychotherapy in place of the physician prescription (except for Medicaid). This prescription will be entered into the treatment record.

Ordinarily, it is good to involve the primary care physician in mental health or AODA services, so the option of using the physician to provide the prescription for psychotherapy remains the best option in most cases.

E. Co-occurring AODA/mental health problems

If a clinic provides substance use services under DHS 75, the clinic shall use a department approved placement criteria tool to determine if a consumer who has a co-occurring substance use disorder requires a system for managing the effects of severe intoxication or the effects of withdrawal from a substance (detoxification services), in a medical or a non-medical setting. If the level of substance use services needed by the consumer is above the level that can be provided by the clinic, the person will be referred to an appropriate department certified provider.

 

DHS 35.165 Emergency services

Staff who identify a crisis situation unfolding in the clinic will take reasonable and prudent steps to address the problem on the spot through their personal intervention and/or calling someone else for the purpose of addressing the situation. Crises in people’s lives that become apparent through clinical contact in the office or in the field will be addressed in a manner consistent with established professional guidelines and clinic policy. Crises will be brought to the attention of the police if there is imminent danger. The clinic crisis intervention service is available to evaluate risk in the community and to develop a crisis intervention plan if the individual is at risk of harming self or others. It is important for the crisis intervention service and other clinic services to coordinate in developing the crisis intervention plan. If the individual is hospitalized in a psychiatric hospital, or placed in a crisis stabilization facility, clinic staff will coordinate with these entities on developing a discharge plan. As crises frequently involve AODA, procedures for medical clearance, detoxification, and AODA follow-up will be employed as makes sense in each circumstance. Clinic staff involved in follow-up will coordinate with one another to assure that a crisis plan is developed and followed. The clinic administrator will review crisis response with the staff involved and will ensure that staff are trained and supervised in handling crisis situations. The clinic administrator will also guide staff in developing crisis plans for the prevention of future crises.

 

DHS 35.17 Assessment

The initial assessment and treatment plan will be completed before the second meeting with the person, as described above. The initial assessment shall be sufficient to identify the consumer’s need for outpatient mental health services.

A comprehensive assessment in the form of the intake summary will follow the initial assessment. The comprehensive assessment will be typed, and will be completed before the review with the supervisor takes place, which is within 30 days of intake, at the longest. The comprehensive assessment will include the following:

1. The consumer’s presenting problems.

2. A diagnosis established from the current DSM.

3. The recipient’s symptoms which support the given diagnosis.

4. Information on the consumer’s strengths, and current and past psychological data; information related to school or vocational, medical, and cognitive functioning; past and present trauma; and substance abuse.

5. Information on current habits of living, life-style, and relationships.

6. Information on current life stressors.

7. Information on current and past medical treatment or other services.

 

8. Information on co-occurring disorders.

 

9. Identification of services outside of the clinic not yet provided that should be considered with a possible referral to another provider.

10. Information on current and past problems with the law, family situation, and living arrangement.

 

11. Information on cultural and ethnic influences on the consumer.

12. The consumer’s unique perspective and own words.

The comprehensive assessment will be presented in narrative form, and will be sufficient to establish the patterns and dynamics of the person’s life, which has significance beyond a review of static symptoms or conditions. Thus, treatment focuses on the flow of energy, the forces acting on the individual in the day-to-day environment in which the consumer lives.

 

DHS 35.18 Consent for outpatient mental health services

The consent procedures have been referenced above, in section DHS 16, which refers to the admission procedures. Admission as used herein is admission to psychotherapy or psychotropic medication therapy. These are the two services of the clinic which are the primary focus of the state clinic regulations, which apply equally to public and private clinics. However, other mental health services also occur in a clinic, meaning services other than psychotherapy and medication therapy. A clinic could not operate without a variety of services, formal or informal, being offered to consumers.

Public sector clinics differ from private sector clinics largely by developing more services in the "other" category. Private sector clinics usually have office support staff, psychotherapists, and psychiatrists, and that’s it. Public sector clinics have these plus a cadre of nurses and case managers and paraprofessionals to address the needs of the consumer. Public sector clinics usually extend services into the community, connecting with systems out there, and with natural support persons in the consumer’s life. The public clinic is also responsible for maintaining the community safety net, which, in some cases means, placement of the individual in a psychiatric inpatient hospital, or other residential setting, sometimes against their will, using a court order. Mental health social services and crisis intervention services consistent with maintaining the public safety net are part of the social mandate in a public clinic, which is largely funded by tax dollars. This mandate does not apply to private sector clinics. Private sector clinics typically have no formal mental health case management programs at all, and no direct responsibility for emergency services provided to the community at large, that is, to people who are not enrolled in their programs.

Consent for services here means consent for psychotherapy and/or medication therapy provided through the clinic. The Consent for Treatment and Services form is employed for this purpose, to enter someone into these office-based services. The consent procedures for the other services provided in a public clinic vary by the service provided, and are not equal to the consent procedures required for outpatient psychotherapy or outpatient psychotropic medication management..

The consent for psychotherapy and psychotropic medication services is a formal process. The consent is based on informing the consumer about what happens in an outpatient clinic, what is involved in psychotherapy, what is involved in medication therapy. The professional will give the consumer feedback to improve their understanding of their particular mental health problem, and how this problem affects their everyday life; the professional will talk to the consumer about options for addressing the problem, including things that they will have to do, things the mental health professional can do, and options to consider. The goals for treatment will be outlined, and the methods used to reach those goals will be discussed. The consumer will then be offered the choice of whether or not they wish to proceed, and if they do, they will be asked to consent to the treatment and services identified. A consent form is provided for their signature.

Thusly, the mental health professional and the consumer enter into a contract for services. This contract is established in the intake session, with the language of the agreement being contextualized, that is, embedded in the emotions and dynamics of this meeting, as occurs naturally when people make agreements. If there is hesitation or if additional questions appear which cannot be answered, the mental health professional will offer a space of time for the consumer to consider further whether or not they wish to enter into that kind of treatment, and will also offer suggestions on what the consumer might do in the meantime to make their decision. The advantages and disadvantages of treatment will be discussed, which includes alternatives that the person may wish to pursue instead. If there are elements of coercion impacting the decision, such as threats of punishment or ultimatums from others to proceed or not to proceed, the mental health professional will offer options to the person for responding to that outside authority (or family member, or employer, etc.). Other situations may call for the mental health professional to give a warning or to take immediate action to protect life, the consumer’s or somebody else’s. If this scenario arises, the mental health professional will inform the consumer that other people may be contacted, such as the police, to address the safety issue. The latter situation may develop during a mental health crisis, or when the consumer makes statements or displays actions that could lead to harm. The mental health professional should identify potential safety issues in the community, even when the individual does not directly mention those issues, and should identify problem behaviors that amplify the mental health problem, even though the consumer considers those behaviors unimportant or skips over them. Thus, the mental health professional structures the intake session in such a way that information can be put on the table for consideration, and a narrative is constructed, which identifies the problem (diagnostic formulation), the factors contributing to the problem (etiology), the goals of treatment, and the methods employed for getting there. This process entails attention to positive information, that which is readily put on the table up front, and attention to latent information, that which is not put on the table, but needs to be developed as part of the narrative. This narrative is the product of the therapeutic process. A meaningful narrative stands as an authority to guide the consumer. The consumer learns to use their narrative as a reference point in making decisions. Building the narrative for the consumer’s benefit is central to the practical art of performing psychotherapy or psychiatric services.

Notwithstanding human foibles and weaknesses, the mental health professional will establish a broad framework of consent with the consumer that is sufficient to allow them to proceed, and which motivates the consumer to move along the path of recovery. The consent process is also a way to frame the issues to be addressed in treatment.

If the consumer remains dubious about consenting to services at the end of the first session, the treatment professional will suggest remedies to resolve this doubt. Such options may require that additional steps be taken by the professional or the consumer, or by other people, before an adequate level of consent can occur to start the treatment process. In such circumstance, the steps to be taken will be explained to the consumer, which may be written on the consent form, signed by the consumer, or alternatively, written on the Initial Assessment and Treatment Plan form, which the consumer will sign. The next meeting, the second meeting, can then occur to establish whether or not the steps to procure consent have been taken, and what the consumer is asking for at that point. Then the mental health professional will offer a new consent form to be signed by the consumer, identifying the updates to the plan, or will clarify via note that the issues have been addressed and the consumer is consenting to services.

Such a scenario may also develop if the mental health professional has doubts that the person is a proper subject for treatment, employing the mediums of psychotherapy or medication therapy, either because the mental health problem is unclear, or something else, a different option, would have more power to address the issue. This scenario often develops with children, and with some adults, who need crisis intervention or some other service which can more easily bring forth a community organizing approach, if such an approach is required to address the issue. In other circumstances, the professional may determine that a mental health problem is secondary or tertiary to some other major problem that is crying to be addressed first. The mental health professional must defer from providing treatment if that treatment offers slight chance of helping, but is obligated to explain what those alternative steps should be.

Most intake sessions will result in a satisfactory agreement which allows the treatment process to proceed. The consent being offered is based on agreement that the following statements are true:

1. The results of the assessment have been presented verbally and in writing on the Initial Assessment and Treatment Plan form and questions have been answered.

 

2. The purpose of treatment has been explained.

3. Treatment alternatives have been discussed, or an opportunity has been offered.

 

4. Possible outcomes and side effects, or drawbacks, of the treatment offered have been discussed.

5. The treatment recommendations have been offered, including the benefits of treatment.

6. The approximate duration and the desired outcome of treatment has been explained.

7. The rights of the consumer have been presented, including the consumer’s responsibilities in the development and implementation of the treatment plan.

8. The services being offered have been identified by name, and the basic features of that treatment have been described.

9. The fees have been explained and the consumer has consented to the financial obligation incurred upon entering services as stated on the Financial Agreement Form.

10. Information on how to use the clinic’s grievance procedure has been offered.

11. The means by which a consumer may obtain emergency mental health services during periods outside of normal operating hours of the clinic have been explained.

12. The clinic’s discharge policy has been presented, including what happens when a person fails an appointment or cancels late (less than 24 hours notice), or fails to make payments for services.

The consent form is signed and dated by the person (or legal representative) at the time of the first meeting. The terms of this consent can be modified at any time, as so indicated by note updating the treatment plan. If the consumer is prescribed medication as part of the treatment plan, the clinic shall obtain a separate consent that indicates that the prescriber has explained to the consumer, or the consumer’s legal representative, if the legal representative is required, the nature, risks and benefits of the medication and that the consumer, or legal representative, understands the explanation and consents to the use of medication. Alternatives, or additional mental health services, or other services outside of the clinic, will also be discussed at that time. Consents for treatment must be renewed at least every 15 months.

As part of the consent procedure to be completed in the first session, the consumer will sign the Initial Assessment and Treatment Plan document, but this document alone does not suffice for the overall consent, as the broader consent requires an understanding of obligations, clinic policies, patient rights, and financial burdens incurred.

 

DHS 35.19 Treatment plan

The final treatment plan will accompany the comprehensive assessment as part of the intake summary. Ordinarily, the intake summary is typed. The final treatment plan and the initial treatment plan are lined up, meaning the final treatment plan is substantially a restatement of the initial treatment plan which was completed on the first day of services, although the final plan may add more details on who, what, when, where, and why (the five Ws of treatment planning). If the treatment plan changes substantially between the initial and final plan, the change will be discussed verbally with the consumer, as to what changed, the reasons for the change, and what impact that will have on treatment. The consumers response to this conversation will be identified in a progress note. If the treatment plan is changed after the final plan has been written and entered into the chart, a similar process will occur.

The treatment plan is a work in progress, meaning that it may be expanded, reduced, or otherwise modified as new information and circumstances emerge. This planning process is a continuous, ongoing conversation between the therapist and the consumer. The documents referencing the plan and progress notes will reflect this development. The treatment plan describes all of the following:

1. The consumer’s strengths and how these will be developed.

2. A description of the primary problems in functioning day-to-day and how these problems will be addressed.

3. Consideration of developmental needs, especially for a child or adolescent, and how these organize the individual’s responses in day-to-day living.

4. The schedules, frequency, and nature of services recommended.

5. The current needs and goals of the consumer.

6. A statement of goals and measurable outcomes expected from treatment.

7. An ongoing review of goals and progress towards outcomes, and discussion of methods for achieving the results desired with the consumer, if any of these change or need further clarification.

 

8. Any statements by the consumer reflecting their assessment of progress or lack thereof, and suggestions for modification, requested by the consumer, or proposed by the therapist, with a summary of the consumer’s response.

9. Disagreements in treatment planning will be identified in the notes and how these disagreements were addressed.

10. Each meeting with the consumer results in a clinical review of the plan and progress towards goals, based on observation and statements made by the consumer, or collaterals.

11. A written treatment plan update will be completed at least every 90 days or six treatment sessions, whichever comes first.

12. Statements for referring the consumer to another community service provider, or recommendations for changing routines in day-to-day living will be documented in the notes, along with the consumer response.

Referrals to other providers in the clinic or outside of the clinic must be connected to the goals in the plan, and must be reasonably achievable, that is, the service must be accessible to the consumer, and likely to produce value-added results, given the problems and the means of the consumer. The referral must be made considering the advantages and disadvantages of the prospective service, including possible impact on the current therapy. The advantages and disadvantages of a referral will be discussed with the consumer, and the consumer’s response will be noted.

In summary, the treatment plan is a process continually under development. The consumer and the therapist engage in discussion of this plan as it is developed. Documents in the chart reflect this treatment planning, beginning with the initial plan, followed by the plan summarized in the intake summary, which includes the comprehensive assessment, followed by treatment plan updates. Modifications of the plan will be noted in the progress notes. Formal treatment plan updates will be completed every 90 days or six sessions, whichever occurs last (in yellow). These plan updates will be done with the consumer, and will be signed by them, as well as by the professional.

 

 

DHS 35.20 Medication management

The clinic will provide medication management as part of the clinic services. Consumers who wish to be seen by the psychiatrist for medication therapy will be seen first by a therapist who will conduct an intake session to determine history of the problem, nature of the social support system, psycho-social stressors, family dynamics, legal problems, current and past AODA, and occupational status, among other things. The therapist will describe how these issues in day-to-day living relate to the mental health problems of the person seeking services. The therapist may recommend psychotherapy or other service, may recommend use of the family physician instead to obtain medications, or may refer the consumer directly to the psychiatrist. Services may occur concomitantly for many consumers. Others will be considered "doctor only", until such time as circumstances change, or the consumer requests "counseling", or some other form of assistance. The clinic administrator will assist the therapist and the psychiatrist in determining who will be seen by the psychiatrist, and when. If additional information is necessary, such as records from previous treatment facilities, or a listing of all medications, and current physical health records, the therapist will attempt to obtain that information before the person sees the psychiatrist. For those persons receiving medications from the psychiatrist, a list of medications prescribed will be maintained in the file, as will a medication administration record if clinic staff dispense or administer medications to the consumer. The clinic shall obtain a separate consent that indicates that the prescriber has explained to the consumer, the nature, risks, and benefits of the medication and that the consumer, understands the explanation and consents to the use of the medication. The psychiatrist will maintain a log of all medications prescribed, reduced, increased, or discontinued, and the date of the change. This record will be continuous for the entire time the consumer has been in services at the clinic. This document is identified as the Medication Sheet.

 

DHS 35.21 Treatment approaches and services

A treatment policy will be established for each consumer enrolled in services at the clinic. A policy for each person registered in treatment (the identified client) is necessary because of their unique personal characteristics and the natural variation of personal circumstance. Generalized categories too often miss the importance of individual values, natural inclinations, enduring habit, traditions, cultural background, and pressures from the environment, which are so important in organizing a person’s behavior. Each individual is a combination of common and unique attributes. The individualized policy will include the treatment plan, but will go beyond that in indicating what should or should not be done in specific circumstances or in response to specific behaviors. In other words, the policy will be contextualized. Supervision will help establish this policy for the person. This is the treatment narrative, which is unique to each person. Clinic staff in contact with the consumer will employ this treatment narrative in responding to the person. Peer reviewed journal articles may contribute to treatment policies, but, generally speaking, strategies based on research findings have to be adapted to the specific individual. The clinic will make reasonable efforts to ensure that each consumer receives services that are supported in the research literature, and the services specifically identified in the treatment plan.

General categories are useful, but people are not walking, talking mental illnesses, nor is treatment one dimensional. The individual treatment policy will blend the general and the particular, and the multiple domains of a person’s life.

 

DHS 35.22 Discharge summary

The therapist or the psychiatrist shall prepare a discharge summary within 30 days after the date of discharge. In many cases it is difficult to clearly fix the date of discharge, as someone may miss appointments two or three months in a row and may still intend to make another appointment, or may understand that the option is open for them to make another appointment. This is how it should be -- it is natural for people to keep the option open of coming back in again, when they feel they need it. It is a way for people to feel comfortable enough to end the outpatient treatment by just fading away. If the issues have not changed, a lapse of three months contact does not invalidate the previous treatment plan. In psychotherapy, the need for an occasional "booster" session is not atypical. Thus, the date of discharge cannot be fixed until the end of the treatment episode. Individuals may cycle through more than one treatment episode over a period of years.

The date of discharge can be fixed in four ways:

1. By mutual agreement. The discharge date would then be the date of the last appointment.

2. Through notification that the person is seeking services elsewhere, or through notification that the person does not wish to reschedule. Then the date would be the date the clinic was notified.

3. By a pattern of failed or cancelled late appointments. This date would be determined by the psychotherapist who says don’t reschedule the person.

4. By a lapse of six months without contact. This date would be six months from the last date of contact.

If the person calls after a lapse of several months, clinic staff will ask if anything has changed in the meantime, to determine if the financial information is the same as before, and if the clinical goals have changed. If the financial information has changed, the consumer will complete a new financial agreement form, an event that could also occur during a period of active, ongoing treatment. If the clinical goals have changed, the fresh contact should result in a new intake, as then all intake documents will have to be renewed.

Subsequent to fixing the date of discharge through one of the above routes, a fresh contact will require a new intake to be completed.

A discharge summary will include all of the following:

1. A description of the reasons for discharge.

2. A summary of the mental health services provided by the clinic, including

medication services.

3. An evaluation of the person’s progress towards goals at the end of the treatment episode.

4. Any remaining consumer needs at the time of discharge, and recommendations for addressing those needs, which become pertinent if later the person seeks treatment again, or someone requests records from the clinic after discharge.

The discharge summary will be in narrative form, and will be signed and dated by the professional who provided the services. At the time of discharge the professional will also complete a Consumer Outcomes form (in blue).

 

DHS 35.23 Consumer file

The clinic will maintain a consumer file for each consumer who receives outpatient mental health services. Each consumer file shall be arranged in a format that provides for consistent record keeping that facilitates accurate and efficient retrieval of record information. All entries in the consumer file shall be factual, accurate, legible, permanently recorded, dated, and authenticated with the signature and license or title of the person making the entry.

Each consumer file shall include accurate documentation of all outpatient mental health services received including all of the following:

1. Results of each assessment conducted.

2. Initial and updated treatment plans.

3. The recommendation or prescription for psychotherapy.

4. For consumers who are diagnosed with substance abuse disorder, a completed copy of the most current approved placement criteria summary (co-occurring disorders).

5. Documentation of referrals of the consumer to outside resources.

6. Descriptions of significant events that are related to the consumer’s treatment plan and contribute to an overall understanding of the consumer’s ongoing level and quality of functioning.

7. Progress notes, which shall include documentation of therapeutic progress, functional status, treatment plan progress, symptom status, change in diagnosis, and general management of treatment.

8. Any recommended changes or improvement of the treatment plan resulting from clinical collaboration or clinical supervision.

9. Signed consent forms for disclosure of information and for medication administration and treatment, and court orders, if any.

10. A listing of medications prescribed by staff prescribers, and a medication administration record if staff dispenses or administers medications to the consumer.

 

11. A record of the admission screening, and all other intake documents, including releases of information.

12. Intake summary with comprehensive assessment and treatment plan.

13. Discharge summary and any related information.

14. Notice of involuntary discharge from outpatient services if applicable.

15. Records from outside agencies that pertain to the person’s mental health problems, including a record of previous treatment.

16. Any other information that is appropriate for the consumer file.

Treatment records shall be kept confidential in a designated place in each clinic office at what records are stored that is not accessible to consumers or the public but is accessible to appropriate staff members at all times. The treatment record, or relevant parts of it, can be transferred to another provider upon the request of the consumer, by making copies of the record. The clinic will maintain a record of the documents sent, the date, and where they were sent. Upon termination of association with the clinic of a staff member, the clinic will retain the treatment records produced by the staff member in the course of treating people at the clinic. Records will be retained for at least seven years in a back-up storage area, which is locked, and not accessible to the public.

 

35.24 Consumer rights

The clinic will follow the standards of s. 51.61 and ch. DHS 94 to protect the rights of consumers. Each consumer will be informed of their rights at the time of intake. If a staff member is no longer employed at the clinic, the clinic will offer consumers who had been served by that staff member options for ongoing services. If the clinic involuntarily discharges a consumer from psychotherapy or medication therapy, meaning unilaterally acts to discontinue services which have been ongoing, over the objections of the consumer, the consumer will be notified of the reasons why this action is occurring, what alternative services are available, in the clinic or elsewhere, and their right to have their discharge reviewed by the department at the state which regulates outpatient mental health clinics.

Ordinarily, such action is prompted by concerns about health or safety of staff at the clinic, resulting from dangerous acts or threats from the consumer. Discharge from services due to inability to profit from them, or due to malingering, could rise to the level of an involuntary discharge if the action is initiated unilaterally by the clinic and if the consumer objects. Discharge from psychotherapy or medication therapy at the office, against the wishes of the consumer, may or may not prevent a clinic from providing necessary services in an alternative manner. Before a situation gets to this level, the clinic and the consumer will usually have addressed most conflicts through the ordinary process of conflict resolution, or the clinic’s grievance procedure.

Discharges from treatment may occur in other ways, as indicated above in section DHS 35.22. The discharges identified in that section are considered voluntary; they do not reach the level of involuntary discharge as defined in this section.