Treatment Planning M.A.T.R.S: Treatment Planning M.A.T.R.S: - - PowerPoint PPT Presentation

Treatment Planning M.A.T.R.S: Treatment Planning M.A.T.R.S: Utilising Utilising the ASI the ASI

Treatnet Training Volume A: Module 3 – Updated 12 February 2008

2

Module 3 Workshops Module 3 Workshops

Workshop 1: Workshop 1: Understanding Treatment Understanding Treatment Planning and the ASI Planning and the ASI Workshop 2: Workshop 2: Treatment Plans Treatment Plans Workshop 3: Workshop 3: Prioritising Prioritising Problems Problems Workshop 4: Workshop 4: Putting Treatment Planning Putting Treatment Planning M.A.T.R.S. into M.A.T.R.S. into Practise Practise

3

Module 3 training goals Module 3 training goals

1. 1.

Increase familiarity with treatment planning Increase familiarity with treatment planning process process

2. 2.

Increase understanding of guidelines and Increase understanding of guidelines and legal considerations in documenting client legal considerations in documenting client status status

3. 3.

Increase skills in using the Addiction Increase skills in using the Addiction Severity Index (ASI) in developing Severity Index (ASI) in developing treatment plans and documenting activities treatment plans and documenting activities

Workshop 1: Workshop 1: Understanding Treatment Planning Understanding Treatment Planning and the ASI and the ASI

5

Pre Pre-

• assessment

assessment

Please respond to the pre Please respond to the pre-

• assessment

assessment questions in your workbook. questions in your workbook.

(Your responses are strictly confidential.) (Your responses are strictly confidential.)

10 Min.

6

Icebreaker Icebreaker

How do you define How do you define treatment planning? treatment planning?

7

Icebreaker: The Good and the Bad Icebreaker: The Good and the Bad

8

The Good and the Bad The Good and the Bad

Negative Aspects of Negative Aspects of Treatment Planning Treatment Planning Positive Aspects of Positive Aspects of Treatment Planning Treatment Planning 1 1 2 2 3 3 4 4 5 5

9

Workshop 1: Training objectives (1) Workshop 1: Training objectives (1) At the end of this workshop, you will be able to: At the end of this workshop, you will be able to: 1. 1. Use ASI information to develop Use ASI information to develop individualised individualised treatment plans treatment plans 2. 2. Identify characteristics of a Identify characteristics of a programme programme-

• driven and an

driven and an individualised individualised treatment plan treatment plan 3. 3. Understand how Understand how individualised individualised treatment treatment plans help to keep people in treatment and plans help to keep people in treatment and lead to better outcomes lead to better outcomes

Continued

10

Workshop 1: Training objectives (2) Workshop 1: Training objectives (2)

At the end of this workshop, you will be able to: At the end of this workshop, you will be able to: 4. 4. Use Master Problem List (provided) to Use Master Problem List (provided) to formulate treatment plans and develop: formulate treatment plans and develop:

• Problem statements

Problem statements

• Goals based on problem statements

Goals based on problem statements

• Objectives based on goals

Objectives based on goals

• Interventions based on objectives

Interventions based on objectives

5. 5. Practise Practise writing documentation notes writing documentation notes reflecting how treatment plan is progressing reflecting how treatment plan is progressing (or not progressing) (or not progressing)

11

What is What is not not included in training included in training

• Administering and scoring the ASI

Administering and scoring the ASI

• Administering any other

Administering any other standardised standardised screening / assessment tool screening / assessment tool

• Training on clinical interviewing

Training on clinical interviewing

12

The goal of this training is The goal of this training is… …

To bring together the To bring together the assessment and treatment assessment and treatment planning processes planning processes

13

“ “Same plan, different names. Same plan, different names.” ”

Treatment plans are often. . . Treatment plans are often. . .

“ “Meaningless & time consuming. Meaningless & time consuming.” ” “ “Ignored. Ignored.” ”

The What, Who, When, The What, Who, When, and How of Treatment and How of Treatment Planning Planning

15

What is a treatment plan? What is a treatment plan?

A written document that: A written document that:

• Identifies the client

Identifies the client’ ’s most important s most important goals for treatment goals for treatment

• Describes measurable, time

Describes measurable, time-

• sensitive

sensitive steps towards achieving those goals steps towards achieving those goals

• Reflects a verbal agreement between

Reflects a verbal agreement between the counselor and client the counselor and client

(Source: Center for Substance Abuse Treatment, 2002)

16

Who develops the treatment plan? Who develops the treatment plan?

Client works with treatment providers to Client works with treatment providers to identify and agree on treatment goals identify and agree on treatment goals and identify strategies for achieving and identify strategies for achieving them. them.

17

• At the time of admission

At the time of admission

• And continually updated and revised

And continually updated and revised throughout treatment throughout treatment When is the treatment plan developed? When is the treatment plan developed?

18

How does assessment guide treatment How does assessment guide treatment planning? planning?

• The Addiction Severity Index (ASI), for

The Addiction Severity Index (ASI), for example, identifies client needs or example, identifies client needs or problems by using a semi problems by using a semi-

• structured

structured interview format interview format

• The ASI guides delivery of services

The ASI guides delivery of services that the client needs that the client needs

19

• Treatment goals address those

Treatment goals address those problems identified by the problems identified by the assessment assessment

• Then, the treatment plan guides the

Then, the treatment plan guides the delivery of services needed delivery of services needed

How does assessment guide treatment How does assessment guide treatment planning? planning?

20

• A reliable and valid instrument, widely

A reliable and valid instrument, widely used both nationally and internationally used both nationally and internationally

• Conducted in a semi

Conducted in a semi-

• structured

structured interview format interview format

• Can be effectively integrated into

Can be effectively integrated into clinical care clinical care

(Sources: Cacciola et al., 1999; Carise et al., 2004; Kosten et al., 1987; McLellan et al., 1980; 1985; 1992)

What is the ASI? What is the ASI?

21

Identifies 7 potential problem areas: Identifies 7 potential problem areas:

1.

• 1. Medical status

Medical status 2.

• 2. Employment and support

Employment and support 3.

• 3. Drug use

Drug use 4.

• 4. Alcohol use

Alcohol use 5.

• 5. Legal status

Legal status 6.

• 6. Family/social status

Family/social status 7.

• 7. Psychiatric status

Psychiatric status

What is the ASI? What is the ASI?

22

The ASI is NOT The ASI is NOT… …

• A personality test

A personality test

• A medical test

A medical test

• A projective test such as the Rorschach

A projective test such as the Rorschach Inkblot Test Inkblot Test

• A tool that gives you a diagnosis

A tool that gives you a diagnosis

23

Why use the ASI? Why use the ASI?

1.

• 1. Clinical applications

Clinical applications 2.

• 2. Evaluation uses

Evaluation uses

24

Recent developments Recent developments

• Efforts focused on making the ASI more

Efforts focused on making the ASI more useful for clinical work useful for clinical work

• (Example: Using ASI for treatment

(Example: Using ASI for treatment planning) planning)

• The Drug Evaluation Network System

The Drug Evaluation Network System (DENS) (DENS) Software uses ASI information to Software uses ASI information to create a clinical narrative create a clinical narrative

25

ASI is now ASI is now more more clinically useful! clinically useful!

New and Improved DENS Software New and Improved DENS Software (2005) (2005)

Uses ASI information to define possible Uses ASI information to define possible problem lists and prompt and guide problem lists and prompt and guide clinician in developing a treatment plan. clinician in developing a treatment plan.

26

• Uses a semi

Uses a semi-

• structured interview to

structured interview to gather information a clinician gather information a clinician generally collects during assessment generally collects during assessment

• Shown to be an accurate or valid

Shown to be an accurate or valid measure of the nature and severity of measure of the nature and severity of client problems client problems

Clinical application Clinical application

(Sources: Kosten et al., 1987; McLellan et al., 1980; 1985; 1992)

Why use the ASI? Why use the ASI?

27

• Prompts clinician to focus session on

Prompts clinician to focus session on important problems, goals, and important problems, goals, and

• bjectives
• bjectives
• Basis for reviews of progress during

Basis for reviews of progress during treatment and documentation treatment and documentation

• Basis for discharge plan

Basis for discharge plan

Clinical application Clinical application

Why use the ASI? Why use the ASI?

28

NIDA Principle 3: NIDA Principle 3:

“ “To be effective, treatment must address the To be effective, treatment must address the individual individual’ ’s drug use and any associated s drug use and any associated medical, psychological, social, vocational, and medical, psychological, social, vocational, and legal problems. legal problems.” ”

The ASI assesses all these dimensions. The ASI assesses all these dimensions.

Clinical application Clinical application

Why use the ASI? Why use the ASI?

29

Clinical Clinical application application

30

Clinical use of ASI improves rapport Clinical use of ASI improves rapport

“ “. . . If patients . . . If patients’ ’ problems are accurately problems are accurately assessed, they may feel assessed, they may feel ‘ ‘heard heard’ ’ by their by their counsellor counsellor, potentially leading to the , potentially leading to the development of rapport and even a stronger development of rapport and even a stronger helping alliance. helping alliance.” ”

(Sources: Barber et al., 1999, 2001; Luborsky et al., 1986, 1996)

Clinical application Clinical application

31

“ “. . . Patients whose . . . Patients whose problems are identified at problems are identified at admission, and then admission, and then receive services that are receive services that are matched to those matched to those problems, stay in treatment problems, stay in treatment longer. longer.” ”

(Sources: Carise et al., 2004; Hser et al., 1999; Kosten et al., 1987; McLellan et al., 1999)

Clinical application Clinical application

Using ASI to match services to client Using ASI to match services to client problems improves retention. problems improves retention.

32

For For Programme Programme Directors: Directors:

• Identifies types of client problems

Identifies types of client problems not addressed through the not addressed through the programme programme’ ’s s treatment services treatment services

• Quantifies client problems

Quantifies client problems

• Identifies trends over time

Identifies trends over time

Evaluation uses Evaluation uses

Continued

33

For For Programme Programme Directors: Directors:

• Assists with level

Assists with level-

• of
• f-
• care choices

care choices

• Provides measure of

Provides measure of programme programme success success

• Documents unmet client service

Documents unmet client service needs needs

• Includes data needed for reports to

Includes data needed for reports to various stakeholders various stakeholders

Evaluation uses Evaluation uses

Continued

34

For For Programme Programme Directors Directors

• Positions

Positions programmes programmes for for increased funding though increased funding though participation in clinical trials and participation in clinical trials and

• ther research opportunities
• ther research opportunities

Evaluation uses Evaluation uses

35

For Clinical Supervisors For Clinical Supervisors

ASI data can be used to ASI data can be used to

• Identify

Identify counsellor counsellor strengths and strengths and training needs training needs

• Match clients to

Match clients to counsellor counsellor strengths strengths

• Identify trends in client problems

Identify trends in client problems

Evaluation uses Evaluation uses

36

Workshop 2: Treatment plans Workshop 2: Treatment plans

Programme-Driven Individualized versus

37

Biological Psychological Sociological

Biopsychosocial Model Biopsychosocial Model

38

Sociological

Does the client have a car? Can they access public transportation?

Biopsychosocial Model example ... Biopsychosocial Model example ...

How close do they live to the treatment centre? How available are drugs or alcohol in the home?

39

Biological

(e.g., medical status)

Psychological

(e.g., psychiatric status)

Sociological

(e.g., family & social status)

ASI problem domains and the ASI problem domains and the biopsychosocial biopsychosocial model model

40

Field of substance abuse treatment: Early work Field of substance abuse treatment: Early work

Programme Programme-

• Driven Plans

Driven Plans “ “One size fits all One size fits all” ”

41

• Client needs are not important as the client is

Client needs are not important as the client is “ “fit fit” ” into the standard treatment into the standard treatment programme programme regimen regimen

• Plan often includes only standard

Plan often includes only standard programme programme components (e.g., group, individual sessions) components (e.g., group, individual sessions)

• Little difference among clients

Little difference among clients’ ’ treatment treatment plans plans

Programme Programme-

• driven plans

driven plans

42

Programme Programme-

• driven plans

driven plans

Client will . . . Client will . . . 1.

• 1. “

“Attend 3 Alcoholic Anonymous meetings Attend 3 Alcoholic Anonymous meetings a week a week” ” 2.

• 2. “

“Complete Steps 1, 2, & 3 Complete Steps 1, 2, & 3” ” 3.

• 3. “

“Attend group sessions 3 times / week Attend group sessions 3 times / week” ” 4.

• 4. “

“Meet with Meet with counsellor counsellor 1 time / week 1 time / week” ” 5.

• 5. “

“Complete 28 Complete 28-

• day

day programme programme” ”

“Still don’t fit right”

43

Programme Programme-

• driven plans

driven plans

• Often include only those services

Often include only those services immediately available in agency immediately available in agency

• Often do not include referrals to

Often do not include referrals to community services (e.g., parenting community services (e.g., parenting classes) classes)

“ONLY wooden shoes?”

44

Individualised Treatment Plans

• Many colors / styles available -

Treatment planning: A paradigm shift Treatment planning: A paradigm shift

• Custom style & fit -

45

Individualised Individualised plan plan

“Sized” to match client’s problems and needs

46

To To individualise individualise a plan, what a plan, what information is needed? information is needed?

1.

• 1. What does a

What does a counsellor counsellor need to need to discuss with a client before developing discuss with a client before developing a treatment plan? a treatment plan? 2.

• 2. Where do you get the information,

Where do you get the information, guidelines, tools, etc.? guidelines, tools, etc.?

47

To To individualise individualise a plan, what a plan, what information is needed? information is needed?

Possible sources of information Possible sources of information might include: might include:

• Probation reports

Probation reports

• Screening results

Screening results

• Assessment scales

Assessment scales

• Collateral interviews

Collateral interviews

48

Case A assessment information: Jan Case A assessment information: Jan

• 27

27-

• year

year-

• old, single Caucasian female
• ld, single Caucasian female
• 3 children under age 7

3 children under age 7

• No childcare available

No childcare available

• Social companions use drugs / alcohol

Social companions use drugs / alcohol

• Unemployed

Unemployed

• Low education level

Low education level

• 2 arrests for possession of

2 arrests for possession of meth meth & & cannabis plus 1 probation violation cannabis plus 1 probation violation

49

Case B assessment information: Dan Case B assessment information: Dan

• 36

36-

• year

year-

• old, married African
• ld, married African-
• American male

American male

• 2 children

2 children

• 2 arrests and 1 conviction for DUI (driving

2 arrests and 1 conviction for DUI (driving under the influence of alcohol) under the influence of alcohol)

• Blood alcohol content at arrest

Blood alcohol content at arrest -

• .25

.25

• Employed

Employed

• High severity family problems

High severity family problems

50

The The “ “Old Method Old Method” ”: : ( (Programme Programme-

• Driven) Problem Statement

Driven) Problem Statement

• Not

Not individualised individualised

• Not a complete sentence

Not a complete sentence

• Doesn

Doesn’ ’t provide enough information t provide enough information

• A diagnosis is not a complete

A diagnosis is not a complete problem statement problem statement

“ “Alcohol dependence Alcohol dependence” ”

51

• Not specific for Jan or Dan

Not specific for Jan or Dan

• Not helpful for treatment planning

Not helpful for treatment planning

• Cannot be accomplished by

Cannot be accomplished by programme programme discharge discharge

“ “Will refrain from all substance use now Will refrain from all substance use now and in the future and in the future” ”

The The “ “Old Method Old Method” ”: : ( (Programme Programme-

• Driven) Goal Statement

Driven) Goal Statement

52

• Again, not specific for Jan or Dan

Again, not specific for Jan or Dan

• A level of care is not an objective

A level of care is not an objective

“ “Will participate in outpatient Will participate in outpatient programme programme” ”

The The “ “Old Method Old Method” ”: : ( (Programme Programme-

• Driven) Objective Statement

Driven) Objective Statement

53

• This sounds specific, but it describes

This sounds specific, but it describes a a programme programme component component

“ “Will see a Will see a counsellor counsellor once a week and

• nce a week and

attend group on Monday nights for 12 attend group on Monday nights for 12 weeks weeks” ”

The The “ “Old Method Old Method” ”: : ( (Programme Programme-

• Driven) Intervention Statement

Driven) Intervention Statement

54

Why make the effort? Why make the effort?

Individualised Individualised Treatment Plans: Treatment Plans:

• Lead to increased retention rates,

Lead to increased retention rates, which are shown to lead to improved which are shown to lead to improved

• utcomes
• utcomes
• Empower the counselor and the client,

Empower the counselor and the client, and give focus to counseling sessions and give focus to counseling sessions

55

Why make the effort? Why make the effort?

Individualized Treatment Individualized Treatment Plans: Plans:

• Like a good pair of shoes, this

Like a good pair of shoes, this plan plan “ “fits fits” ” the client well the client well

ASI: ASI:

• Like measurements, the ASI

Like measurements, the ASI items are used to items are used to “ “fit fit” ” the the client client’ ’s services to her or s services to her or his needs his needs

What is included What is included in any treatment plan? in any treatment plan?

57

Treatment plan components Treatment plan components

• 1. Problem Statements
• 3. Objectives
• 2. Goal Statements
• 4. Interventions

58

1.

• 1. Problem Statements

Problem Statements are based on are based on information collected during the information collected during the assessment assessment

Treatment plan components Treatment plan components

2.

• 2. Goal Statements

Goal Statements are based on the are based on the problem statements and are problem statements and are reasonably achievable in the active reasonably achievable in the active treatment phase treatment phase

59

• Van* is experiencing increased tolerance for

Van* is experiencing increased tolerance for alcohol as evidenced by his need for more alcohol as evidenced by his need for more alcohol to become intoxicated or achieve the alcohol to become intoxicated or achieve the desired effect desired effect

Problem statement examples Problem statement examples

• Meghan* is currently pregnant and requires

Meghan* is currently pregnant and requires assistance obtaining prenatal care assistance obtaining prenatal care

• Tom

Tom’ ’s* psychiatric problems compromise s* psychiatric problems compromise his concentration on recovery his concentration on recovery

*You may choose to use client *You may choose to use client’ ’s last name instead, e.g., Mr. Pierce, Ms. Hunt. s last name instead, e.g., Mr. Pierce, Ms. Hunt.

60

• Van will safely withdraw from alcohol,

Van will safely withdraw from alcohol, stabilise stabilise physically, and begin to establish a physically, and begin to establish a recovery recovery programme programme

Goal statement examples Goal statement examples

• Meghan will obtain necessary prenatal care

Meghan will obtain necessary prenatal care

• Reduce the impact of Tom

Reduce the impact of Tom’ ’s psychiatric s psychiatric problems on his recovery and relapse problems on his recovery and relapse potential potential

61

3.

• 3. Objectives

Objectives are what the client will do to

are what the client will do to meet those goals meet those goals 4.

• 4. Interventions

Interventions are what the staff will do to

are what the staff will do to assist the client assist the client

Other common terms:

• Action Steps
• Measurable activities
• Treatment strategies
• Benchmarks
• Tasks

Treatment plan components Treatment plan components

62

• Van will report acute withdrawal symptoms

Van will report acute withdrawal symptoms

Examples of objectives Examples of objectives

• Meghan will visit an OB/GYN physician or

Meghan will visit an OB/GYN physician or nurse for prenatal care nurse for prenatal care

• Tom will list 3 times when psychological

Tom will list 3 times when psychological symptoms increased the likelihood of symptoms increased the likelihood of relapse relapse

• Van will begin activities that involve a

Van will begin activities that involve a substance substance-

• free lifestyle and support his

free lifestyle and support his recovery goals recovery goals

63

• Staff medical personnel will evaluate Van

Staff medical personnel will evaluate Van’ ’s s need for medical monitoring or medications need for medical monitoring or medications

Intervention examples Intervention examples

• Staff will review Tom

Staff will review Tom’ ’s list of 3 times when s list of 3 times when symptoms increased the likelihood of symptoms increased the likelihood of relapse and discuss effective ways of relapse and discuss effective ways of managing those feelings managing those feelings

• Staff will call a medical service provider or

Staff will call a medical service provider or clinic with Meghan to make an appointment clinic with Meghan to make an appointment for necessary medical services for necessary medical services

64

Review: Treatment Plan Components Review: Treatment Plan Components

1.

• 1. Problem Statements

Problem Statements (information from assessment)

(information from assessment)

3.

• 3. Objectives

Objectives (what the client will do)

(what the client will do)

2.

• 2. Goal Statements

Goal Statements (based on problem statement)

(based on problem statement)

4.

• 4. Interventions

Interventions (what the staff will do)

(what the staff will do)

65

1.

• 1. Client Strengths*

Client Strengths* are reflected are reflected

Treatment plan components Treatment plan components

2.

• 2. Participants in Planning

Participants in Planning* are * are documented documented

* *The DENS Treatment Planning Software

The DENS Treatment Planning Software includes these components includes these components Other aspects of the client Other aspects of the client’ ’s condition: s condition:

ASI Narrative and ASI Narrative and Master Problem List Master Problem List

67

Master Problem List Master Problem List

Refer to ASI Narrative Report Refer to ASI Narrative Report

(Workshop 2, Handout 1) (Workshop 2, Handout 1)

• Review case study

Review case study

• Focus on problems identified in the:

Focus on problems identified in the:

• alcohol/drug

alcohol/drug domain

domain

• medical

medical domain

domain

• family/social

family/social domain

domain

68

ASI Master Problem List ASI Master Problem List

Master Problem List

Date Date Identified Identified Domain Domain Problem Problem Status Status Date Resolved Date Resolved

Alcohol/Drug Alcohol/Drug The client reports several or more episodes of drinking alcohol The client reports several or more episodes of drinking alcohol to intoxication in past month. to intoxication in past month. The client reports regular, lifetime use of alcohol to The client reports regular, lifetime use of alcohol to “ “intoxication. intoxication.” ” The client reports using heroin in past month. The client reports using heroin in past month. Medical Medical Client has a chronic medical problem that interferes with Client has a chronic medical problem that interferes with his/her life his/her life Family/Social Family/Social The client is not satisfied with how he/she spends his/her free The client is not satisfied with how he/she spends his/her free time time The client reports having serious problems with family The client reports having serious problems with family members in the past month members in the past month The client is troubled by family problems and is interested in The client is troubled by family problems and is interested in treatments treatments

69

Considerations in writing Considerations in writing

• All problems identified are included

All problems identified are included regardless of available agency services regardless of available agency services

• Include all problems whether deferred or

Include all problems whether deferred or addressed immediately addressed immediately

• Each domain should be reviewed

Each domain should be reviewed

• A referral to outside resources is a valid

A referral to outside resources is a valid approach to addressing a problem approach to addressing a problem

Master Problem List

70

Tips on writing problem Tips on writing problem statements statements

• Non

Non-

• judgemental

judgemental

• No jargon, such as

No jargon, such as… …

• “

“Client is in denial Client is in denial” ”

• “

“Client is co Client is co-

• dependent

dependent” ”

• Use complete sentence structure

Use complete sentence structure

Problem Statements

71

1.

• 1. Client has low self

Client has low self-

• esteem.

esteem. 2.

• 2. Client is in denial.

Client is in denial. 3.

• 3. Client is alcohol dependent.

Client is alcohol dependent. 4.

• 4. Client is promiscuous.

Client is promiscuous. 5.

• 5. Client is resistant to treatment.

Client is resistant to treatment. 6.

• 6. Client is on probation because

Client is on probation because he is a bad alcoholic. he is a bad alcoholic.

Changing language Changing language

Problem Statements

72

Changing language: Pick two Changing language: Pick two

Problem Statements

• Think about how you might change the

Think about how you might change the language for 2 of the preceding language for 2 of the preceding problem statements problem statements

• Rewrite those statements using non

Rewrite those statements using non-

• judgemental

judgemental and jargon and jargon-

• free language

free language

73

Changing language: Examples Changing language: Examples

Problem Statements

• 1. Client has low self
• 1. Client has low self-
• esteem.

esteem.

• 3. Alcohol Dependent.
• 3. Alcohol Dependent.
• 2. Client is in denial.
• 2. Client is in denial.

– – Client averages 10 negative self Client averages 10 negative self-

• statements daily

statements daily – – Client experiences tolerance, withdrawal, loss Client experiences tolerance, withdrawal, loss

• f control, and negative life consequences due
• f control, and negative life consequences due

to alcohol use to alcohol use – – Client reports two Client reports two DWIs DWIs (driving while (driving while intoxicated) in past year but states that alcohol use intoxicated) in past year but states that alcohol use is not a problem is not a problem

Continued

74

Changing language: Examples Changing language: Examples

Problem Statements

• 4. Client is promiscuous.
• 4. Client is promiscuous.
• 5. Client is resistant to treatment.
• 5. Client is resistant to treatment.
• 6. Client is on probation because he is a bad
• 6. Client is on probation because he is a bad

alcoholic. alcoholic.

– – Client participates in unprotected sex 4 Client participates in unprotected sex 4 times a week with multiple partners times a week with multiple partners – – Client has legal consequences because Client has legal consequences because

• f alcohol
• f alcohol-
• related

related behaviour behaviour – – In past 12 months, client has dropped out of 3 In past 12 months, client has dropped out of 3 treatment treatment programmes programmes prior to completion prior to completion

75

Case study problem statements Case study problem statements

Problem Statements

• Alcohol/drug domain

Alcohol/drug domain

• Medical domain

Medical domain

• Family/social domain

Family/social domain

Write 1 problem statement for each domain. Write 1 problem statement for each domain.

76

ASI Treatment Plan Format ASI Treatment Plan Format

Date Date Identified Identified Domain Domain Problem Problem Status Status Date Date Resolved Resolved

77

Workshop 3: Workshop 3: Prioritising Prioritising problems problems

S M A R T

Now that we have the Now that we have the problems identified problems identified… …how do how do we we prioritise prioritise them? them?

79

Maslow Maslow’ ’s hierarchy of needs s hierarchy of needs

Biological/Physiological Safety & Security Love & Belonging Self-esteem Self-actualisation 1 2 3 4 5

80

PHYSIOLOGICAL

1

Biological/Physiological Biological/Physiological

• Substance Use

Substance Use

• Physical Health Management

Physical Health Management

• Medication Adherence Issues

Medication Adherence Issues

Physical needs Physical needs

81

Safety & Security Safety & Security

2

Mental health management Functional impairments Legal issues

Safety & security Safety & security

82

3

Love & Belonging Love & Belonging

Social & interpersonal skills Need for affiliation Family relationships

Love & belonging Love & belonging

83

4

Self Self-

• Esteem

Esteem

Achievement and mastery Independence/status Prestige

Self Self-

• esteem

esteem

84

5

Self-Actualisation

Self Self-

• actualisation

actualisation

Seeking personal potential Self-fulfilment Personal growth

85

4 5

Self-actualisation Self-esteem

Is “self-esteem” specific?

Self Self-

• esteem & self

esteem & self-

• actualisation

actualisation

Relationship between ASI domains & Relationship between ASI domains & Maslow Maslow’ ’s hierarchy of needs s hierarchy of needs

ASI Domain 5 – Family/Social Relationships ASI Domain 4 – Legal Status ASI Domain 2 – Employment/Support Status ASI Domain 1 - Medical ASI Domain 3 – Drug / Alcohol Use ASI Domain 6 – Psychiatric Status

Biological/ Biological/ Physiological Physiological Safety & Security Safety & Security Love & Love & Belonging Belonging Self Self-

• esteem

esteem Self Self-

• actualisation

actualisation

87

• Pick 3 ASI problem domains for

Pick 3 ASI problem domains for John Smith that appear most John Smith that appear most critical. critical.

• Which domains should be

Which domains should be addressed 1 addressed 1st

st, 2

, 2nd

nd, 3

, 3rd

rd,

, and why? and why?

Practise Practise prioritising prioritising

88

Writing goal statements Writing goal statements

• Use ASI Treatment Plan Handouts

Use ASI Treatment Plan Handouts

• Alcohol / Drug Domain

Alcohol / Drug Domain

• Medical Domain

Medical Domain

• Family / Social

Family / Social

• Write at least 1 goal statement for each

Write at least 1 goal statement for each domain domain

• Write in complete sentences

Write in complete sentences

89

Check Check-

• in discussion

in discussion

• Will the client understand the goal?

Will the client understand the goal?

• (i.e., no clinical jargon)

(i.e., no clinical jargon)

• Clearly stated?

Clearly stated?

• Complete sentences?

Complete sentences?

• Attainable in active treatment

Attainable in active treatment phase? phase?

• Is it agreeable to both client

Is it agreeable to both client and staff? and staff?

90

Treatment M.A.T.R.S. objectives and interventions Treatment M.A.T.R.S. objectives and interventions Measurable Realistic Time-limited

R T M

Attainable

A

Specific

S

91

Measurable Measurable

Objectives and interventions

are measurable

Achievement is observable Indicators of client progress are measurable

Assessment scales / scores Client report Behavioural and mental health status changes

M

M.AT.R.S. objectives & interventions M.AT.R.S. objectives & interventions

92

Attainable Attainable

• Identify objectives and interventions

Identify objectives and interventions attainable during active treatment phase attainable during active treatment phase

• Focus on

Focus on “ “improved functioning improved functioning” ” rather rather than cure than cure

• Identify goals attainable in level of care

Identify goals attainable in level of care provided provided

• Revise goals when client moves from one

Revise goals when client moves from one level of care to another level of care to another

A

M.AT.R.S. objectives & interventions M.AT.R.S. objectives & interventions

93

Time Time-

• limited

limited

Focus on time-limited or short-term goals

and objectives

Objectives and interventions can be

reviewed within a specific time period

T

M.AT.R.S. objectives & interventions M.AT.R.S. objectives & interventions

94

• Client can realistically complete objectives

Client can realistically complete objectives within specific time period within specific time period

• Goals and objectives are achievable given

Goals and objectives are achievable given client environment, supports, diagnosis, client environment, supports, diagnosis, level of functioning level of functioning

• Progress requires client effort

Progress requires client effort

Realistic Realistic

M.AT.R.S. objectives & interventions M.AT.R.S. objectives & interventions

95

Specific Specific

• Specific and goal

Specific and goal-

• focused

focused

• Address in specific

Address in specific behavioural behavioural terms how level of functioning or terms how level of functioning or functional impairments will improve functional impairments will improve

S

M.AT.R.S. objectives & interventions M.AT.R.S. objectives & interventions

96

Problem Statement: Problem Statement: Client reports Client reports regular alcohol use for a period of 15 regular alcohol use for a period of 15

• years. For the past 7 years, he drank
• years. For the past 7 years, he drank

regularly and heavily (5 or more drinks regularly and heavily (5 or more drinks in one day). He reports drinking heavily in one day). He reports drinking heavily 20 of the past 30 days. 20 of the past 30 days.

M.A.T.R.S. clinical example M.A.T.R.S. clinical example

R T M A S

97

Example Goal: Example Goal: Client will safely reduce or

Client will safely reduce or discontinue alcohol consumption discontinue alcohol consumption

Example Objective: Example Objective: Client will continue to

Client will continue to take medication for alcohol withdrawal while take medication for alcohol withdrawal while reporting any physical symptoms (discomfort) reporting any physical symptoms (discomfort) to medical staff for evaluation to medical staff for evaluation

Example Intervention: Example Intervention: Counselor / medical

Counselor / medical staff will meet with client daily to discuss staff will meet with client daily to discuss medication management and presence of medication management and presence of withdrawal symptoms. withdrawal symptoms.

M.A.T.R.S. clinical example M.A.T.R.S. clinical example

R T M A S

98

Do examples pass M.A.T.R.S. guidelines? Do examples pass M.A.T.R.S. guidelines?

M M

What makes these examples What makes these examples measurable measurable? ?

A

What makes these examples What makes these examples attainable attainable? ?

R R

What makes these examples What makes these examples realistic realistic? ?

T T

What makes these examples What makes these examples time time-

• limited

limited? ? What makes these examples What makes these examples specific specific? ?

S S

Workshop 4: Putting Treatment Workshop 4: Putting Treatment Planning M.A.T.R.S. into Planning M.A.T.R.S. into Practise Practise

100

The Stages of Change: Illustrated The Stages of Change: Illustrated

Adapted from Prochaska & DiClemente, 1982; 1986

101

Consider Consider “ “Stages of Change Stages of Change” ”

• 1. Pre-Contemplation
• 2. Contemplation
• 3. Preparation
• 4. Action
• 6. Relapse
• 5. Maintenance

(Source: Prochaska & DiClemente, 1982; 1986)

102

Pre-contemplation

“I don’t have a problem.” Person is not considering or does not want to change a particular behaviour.

103

Person is thinking about changing a behaviour. Pre- Contemplation

Contemplation

“Maybe I have a problem.”

Contemplation

104

Person is seriously considering & planning to change a behaviour and has taken steps towards change.

Pre- Contemplation

Contemplation

Preparation

“I’ve got to do something.”

Preparation

105

Pre- Contemplation

Action

Person is actively doing things to change or modify behaviour.

Contemplation Preparation

Action

“I’m ready to start.”

107

106

Person continues to maintain behavioural change until it becomes permanent.

Maintenance

Contemplation

Pre- Contemplation

Preparation Action

Maintenance

“How do I keep going?”

107

Pre- Contemplation

Contemplation

Preparation

Action Maintenance

Relapse

Relapse

“What went wrong?” Person returns to pattern of behaviour that he or she had begun to change.

108

1.

• 1. Conduct assessment

Conduct assessment 2.

• 2. Collect client data and information

Collect client data and information 3.

• 3. Identify problems

Identify problems 4.

• 4. Prioritise

Prioritise problems problems 5.

• 5. Develop goals to address problems

Develop goals to address problems 6.

• 6. Write M.A.T.R.S.

Write M.A.T.R.S.

• Objectives to meet goals

Objectives to meet goals

• Interventions to assist client in meeting goals

Interventions to assist client in meeting goals

Treatment planning process review Treatment planning process review

Date Date Problem Statement Problem Statement Goals Goals D/C Criteria D/C Criteria Objectives Objectives Interventions Interventions Service Service Codes Codes Target Target Date Date Resolution Resolution Date Date Participation in the Treatment Planning Process Participation in the Treatment Planning Process Participation by Others in the Treatment Planning Process Participation by Others in the Treatment Planning Process

ASI Treatment Plan Format

110

Write 2 objective statements

Required or optional for discharge?

Write 2 intervention statements

Assign service codes and target dates

M.A.T.R.S. objectives & interventions M.A.T.R.S. objectives & interventions

• 1. Alcohol / Drug Domain
• 1. Alcohol / Drug Domain

111

• Measurable? Attainable?

Measurable? Attainable?

Can change be documented? Is it achievable Can change be documented? Is it achievable within active treatment phase? Is it reasonable to within active treatment phase? Is it reasonable to expect the client will be able to take steps on his or expect the client will be able to take steps on his or her behalf? her behalf?

• Time

Time-

• Related? Realistic?

Related? Realistic?

Is time frame specified? Will staff be able to Is time frame specified? Will staff be able to review within a specific period of time? review within a specific period of time? Is it Is it agreeable to client and staff? agreeable to client and staff?

• Specific?

Specific?

Will client understand what is expected and how Will client understand what is expected and how programme programme/staff will assist in reaching goals? /staff will assist in reaching goals?

M.A.T.R.S. objectives/interventions test M.A.T.R.S. objectives/interventions test

112

• 2. Medical Domain
• 2. Medical Domain
• 3. Family/Social Domain
• 3. Family/Social Domain
• Write 2 objective statements

Write 2 objective statements

• Required or optional for discharge?

Required or optional for discharge?

M.A.T.R.S. objectives & interventions M.A.T.R.S. objectives & interventions

• Write 2 intervention statements

Write 2 intervention statements

• Assign service codes and target dates

Assign service codes and target dates

113

Other required elements Other required elements

New, improved DENS Software (2005) New, improved DENS Software (2005)

Guides Guides counsellor counsellor in documenting: in documenting:

• Client strengths

Client strengths

• Participants in planning process

Participants in planning process

114

Documentation: Basic guidelines Documentation: Basic guidelines

Dated, Signed, Legible Referral Information Documented Client Strengths/ Limitations in Achieving Goals Source of Information Clearly Documented Client Name

• n Each Page

115

Entries should include . . . Entries should include . . .

• Your professional assessment

Your professional assessment

• Continued plan of action

Continued plan of action

Documentation: Basic guidelines Documentation: Basic guidelines

116

Describes . . . Describes . . .

• Changes in client status

Changes in client status

• Response to and outcome of

Response to and outcome of interventions interventions

• Observed

Observed behaviour behaviour

• Progress towards goals and

Progress towards goals and completion of objectives completion of objectives

Documentation: Basic guidelines Documentation: Basic guidelines

117

The client The client’ ’s treatment record s treatment record is a legal document is a legal document

Clinical Example:

Agency Trip

Documentation: Basic guidelines Documentation: Basic guidelines

118

Legal Issues & Recommendations: Legal Issues & Recommendations:

• Document non

Document non-

• routine calls, missed sessions,

routine calls, missed sessions, and consultations with other professionals and consultations with other professionals

• Avoid reporting staff problems in case notes,

Avoid reporting staff problems in case notes, including staff conflicts and rivalries including staff conflicts and rivalries

• Chart client

Chart client’ ’s non s non-

• conforming

conforming behaviour behaviour

• Record premature discharges

Record premature discharges

• Note limitations of the treatment provided to the

Note limitations of the treatment provided to the client client

Documentation: Basic guidelines Documentation: Basic guidelines

119

Method of Documentation Method of Documentation

120

S Subjective

ubjective -

• client

client’ ’s observations or s observations or thoughts, client statement thoughts, client statement

O Objective

bjective – – counsellor counsellor’ ’s s observations during

• bservations during

session session

A Assessment

ssessment -

• counsellor

counsellor’ ’s s understanding of understanding of problems and test results problems and test results

P Plan

lan – – goals, objectives, and interventions goals, objectives, and interventions reflecting identified needs reflecting identified needs

S.O.A.P. method of documentation S.O.A.P. method of documentation

121

S.O.A.P. note example S.O.A.P. note example

30 June 2007: Individual Session 30 June 2007: Individual Session S: S: “ “My ex My ex-

• wife has custody of the kids and stands in

wife has custody of the kids and stands in the way of letting me see them. the way of letting me see them.” ” O: Tearful at times; gazed down and fidgeted with O: Tearful at times; gazed down and fidgeted with shirt buttons. shirt buttons. A: Client has strong feelings that family is important in A: Client has strong feelings that family is important in his recovery process. He has a strong desire to be his recovery process. He has a strong desire to be a father to his children and is looking for a way to a father to his children and is looking for a way to resolve conflicts with his ex resolve conflicts with his ex-

• wife.

wife. P: Addressed Tx Plan Goal #4, Action Step 1. P: Addressed Tx Plan Goal #4, Action Step 1. Continue with Tx Plan Goal #4, Action Step 2 in next Continue with Tx Plan Goal #4, Action Step 2 in next session. session.

Mary Smith, CADAC Mary Smith, CADAC

S: S: “ “My ex My ex-

• wife has custody of the kids and

wife has custody of the kids and stands in the way of letting me see them. stands in the way of letting me see them.” ” O: Tearful at times; gazed down and fidgeted with O: Tearful at times; gazed down and fidgeted with shirt buttons. shirt buttons. A: Client has strong feelings that family is A: Client has strong feelings that family is important in his recovery process. He has a important in his recovery process. He has a strong desire to be a father to his children and strong desire to be a father to his children and is looking for a way to resolve conflicts with is looking for a way to resolve conflicts with his ex his ex-

• wife.

wife. P: Addressed Tx Plan Goal #4, Objective 1. P: Addressed Tx Plan Goal #4, Objective 1. Continue with Tx Plan Goal #4, Objective 2 in Continue with Tx Plan Goal #4, Objective 2 in next session. next session.

Tx Plan Reflected in Documentation?

Client quote Physiological

• bservations?

Problem statements, test results, ASI severity ratings, non-judgmental professional assessment Goals, objectives, interventions

123

C Client Condition

lient Condition

H Historical significance of client condition

istorical significance of client condition

A Action

ction – – What action What action counsellor counsellor took in took in response to client condition response to client condition

R Response

esponse – – How client responded to action How client responded to action

T Treatment Plan

reatment Plan – – How it relates to plan How it relates to plan

C.H.A.R.T. method of documentation C.H.A.R.T. method of documentation

(Source: Roget & Johnson, 1995)

Write a Documentation (Progress) Note

Case Note Scenario

You are a case manager in an adult outpatient drug and alcohol treatment programme. You have an active caseload of 25 patients, primarily young adults between the ages of 18 and 25 who have some sort of involvement with the adult criminal justice system. Jennifer Martin is your patient.

Case Manager: “I am glad to see you made it today,

• Jennifer. I was starting to get worried about your attendance for

the past two weeks.”

Jennifer: “I’ve just been really busy lately. You know, it is

not easy staying clean, working, and making counselling

• appointments. Are you really worried about me or are you just

snooping around trying to get information about me to tell my mom and probation officer?”

Case Manager: “You seem a little defensive and

• irritated. Are you upset with me or your mom and your probation
• fficer, or with all of us?”

125

A treatment plan is like the hub in a wheel A treatment plan is like the hub in a wheel

SCREENING & SCREENING & ASSESSMENT ASSESSMENT ONGOING ONGOING DOCUMENTATION DOCUMENTATION DISCHARGE PLAN DISCHARGE PLAN

TX PLAN

REFERRALS REFERRALS INITIAL SERVICE INITIAL SERVICE AUTHORIZATION AUTHORIZATION LEVEL OF CARE LEVEL OF CARE TREATMENT PLAN TREATMENT PLAN REVIEWS REVIEWS Continued Stay Continued Stay Reviews Reviews

127

Other Other organisational

• rganisational considerations

considerations

1.

• 1. Information

Information requirements requirements of funding entities /

• f funding entities /

managed care? managed care? 2.

• 2. Is there

Is there duplication duplication of information collected?

• f information collected?

3.

• 3. Is

Is technology technology used effectively? used effectively? 4.

• 4. Is

Is paperwork useful paperwork useful in treatment planning in treatment planning process? process?

128

Post Post-

• assessment

assessment

Please respond to the post Please respond to the post-

• assessment

assessment questions in your workbook. questions in your workbook.

(Your responses are strictly confidential.) (Your responses are strictly confidential.)

10 Min.

Thank you for your time! Thank you for your time!