DiscoverCounselor Toolbox PodcastTreatment Planning and ReAssessment
Treatment Planning and ReAssessment

Treatment Planning and ReAssessment

Update: 2020-06-27
Share

Description

Counseling CEUs can be earned for this presentation at: https://www.allceus.com/member/cart/index/product/id/1293/c/


Sponsored by TherapyNotes.com

Manage your practice securely and efficiently. Two free months of TherapyNotes with coupon code “CEU”


Secure email provided by https://www.protonmail.com


Treatment Planning and Reassessment

Dr. Dawn-Elise Snipes PhD, LPC-MHSP

Executive Director, AllCEUs

Objectives

– Review multiple ways of writing treatment plans including using the integrative summary, FARS, CANS, ASAM and LOCUS

– Review pitfalls in writing effective treatment plans and how to avoid them

– Review the purpose of the reassessment and best practices for documentation

– Identify time-effective methods for completing treatment plans and reassessments

Integrated Summary & Reassessment

– Purpose

– To summarize the person’s story (Executive Summary) for communication between providers

– To synthesize information to support the diagnosis and level of care

– Drive the treatment plan by identifying

– What the problems are (as evidenced by)

– How they are impacting the patient

– How we are attending to their physical, social, emotional and behavioral needs


Parts of the IS & Reassessment

– A summary of the presenting problem and evidence of impairments

– The person’s diagnosis and evidence

– Recommendations for treatment and defense using ASAM, LOCUS or CANS guidelines

– Current focus of treatment and how the person’s current strengths and needs will be used

– What will be addressed

– Why will it be addressed

– How will it be addressed

– Family involvement (if any)

– Preliminary Relapse Prevention Plan

Writing Good ISs and Reassessments

– The IS and Reassessment are where you get to

– Summarize the facts

– State and support your subjective opinions

– Support your diagnosis

– Support your recommendations for treatment

– Identify initial treatment goals (with the patient)

– Develop a preliminary relapse prevention plan

– They should be a quick read that supports:

– What is wrong

– Why insurance should reimburse for this level of care

– How we are going to assist the patient in a meaningful way improve emotional, behavioral, social, and physical functioning.

Writing Good Ones…

– Read like a reviewer

– What is wrong-

– How is this impacting the person socially, emotionally, physically, occupationally-

– What is maintaining it-

– What strengths and supports are already there, and how can they be used-

– What level of care is recommended

– Why is this level needed

– What are the goals for this level of care

– How can we help the patient avoid a higher level of care-


Rubric for ISs & Reassessments

Pitfalls In Writing Effective Plans & Reassessments

– Failing to use objective, measurable goals

– Not getting client feedback and buy-in


– Failing to ask why the client might lose motivation for change

– Failure to reassess frequently enough and insufficient rewards

Purpose of Planning & Reassessment

– Planning

– Sets measurable & achievable targets

– Helps define the “whys” of interventions

– Increases efficacy through accomplishment

– Frequent Reassessment

– Identifies progress, hurdles and waning motivation

– Provides opportunities for rapid cycle change

Time Effective Documentation

– Get the client’s assistance

– At assessment provide a treatment planning worksheet (4 parts)

– Part 1

– What is important in my rich and meaningful life (people, things, activities)

– Which of those things do I currently have in my life-


Time Effective Documentation

– Part 2

– What problems am I currently having

– PACER Dimensions

– Physical: Health, nutrition, sleep, energy, medication, pain

– Affect: Depression, anxiety, guilt, grief, anger, mania

– Cognition: Attitude and perspective on life, thought process, rumination, negativity, concentration, self awareness, self-esteem, judgment/impulsivity

– Environment: Housing, environmental stressors (sights, smells, sounds, temperature, people, situations)

– Relationships: Family, friends, interpersonal skills,


Time Effective Documentation

– Part 3

– Based on the assessment, what changes do I need to make- Rank them in order from most to least ready to change.

– Part 4

– For each problem identified answer the questions

– When I do not have this problem what is different-

– What can I start doing to address this issue-


Time Effective Documentation

– Get the client(s) to do it with you for empowerment

– Problem: Fatigue

– What will be different when my problem is resolved-

– I will be less fatigued as evidenced by not needing as much caffeine, feeling rested when I awaken in the morning and being able to stay up for 14-16 hours per day.


Reassessment

– Client worksheets (group/individual review sessions)

– Each person is given a copy of their treatment plan

– Reassessment Worksheet

– My goals for this week

– Goal 1: _________________ Accomplished- Yes No

– If no, identify obstacles: (motivation, resources, knowledge, new problems…)

– What changes may need to be made to your treatment plan to address obstacles-


Summary

– A good assessment and integrative summary forms the foundation of an effective treatment plan

– When clients participate, they are empowered and more motivated

– Assessment instruments like the FARS, CANS or LOCUS help the client and clinician identify and define the problems

– Reassessment activities help the client see progress, get support and make adjustments to promote rapid cycle change

Comments 
00:00
00:00
x

0.5x

0.8x

1.0x

1.25x

1.5x

2.0x

3.0x

Sleep Timer

Off

End of Episode

5 Minutes

10 Minutes

15 Minutes

30 Minutes

45 Minutes

60 Minutes

120 Minutes

Treatment Planning and ReAssessment

Treatment Planning and ReAssessment

Charles Snipes