COLLABORATIVE DOCUMENTATION & TRAUMA INFORMED AND CULTURALLY SENSITIVE TREATMENT PLANNING Week 3: Treatment Planning Essentials: Skill Building for Clinicians 1

Welcome Back!  Review of last class  Homework review  What is collaborative documentation ?  Trauma Informed Services 2

Homework Discussion ◦ Feedback from instructors ◦ Strengths ◦ Challenges ◦ Sharing of Treatment Plans in Small Groups (10 mins) 3

WHAT IS COLLABORATIVE DOCUMENTATION? 4

What is Collaborative Documentation ◦ Collaborative Documentation, sometimes referred to as Concurrent Documentation, is a process in which clinicians and clients collaborate in the documentation of the Assessment, Service/Treatment Planning and ongoing Client-Practitioner Interactions (Progress Notes) ◦ The client must be present and engaged in the process of documentation development 5

Re-Integrating Clinical Practice and Clinical Documentation ◦ Documentation has become “The ENEMY” ◦ Clinicians report that documentation competes with time spent with clients ◦ Clinicians count on no-shows to complete paperwork ◦ Clinicians’ “Paper Life” is separated from their “Clinical Life” 6

Collaborative Documentation vs. Post- Session Documentation ◦ Tremendous time savings…. 7 Transitioning from a Post-Session documentation model to a Collaborative Documentation Model can save from 5 to 8 hours per week for full-time staff

Compliance The Big Three ◦ Medical Necessity ◦ Client Participation ◦ Client Benefit 8

Medical Necessity Would you pay for That?? ◦ Every progress note is a bill for services ◦ Would you pay for what you read in a progress note? ◦ We get paid to provide skilled interventions that address assessed behavioral health needs and help a person reach personal life goals. ◦ We do not get paid for “conversations that meander with the client.” 9

Compliance ◦ Documentation Timeliness and Accuracy ◦ What are your documentation timeliness standards? Most are 24 hours! ◦ Other providers within your program and increasingly, outside your program (e.g. physical healthcare partners), should have the benefit of your documentation ◦ Important care coordination and risk management issue ◦ We need to move to “real time” documentation availability (or as close as possible) 10

Collaborative Documentation vs. Post-Session Documentation “It’s not fair to Clients!” 11

Collaborative Documentation Pilot- Client Survey Results 1.On a scale of 1 to 5, how helpful was it to you to have your provider review your note at the end of the session? Percent Total Total % 1.Very Unhelpful7905% 2.Not Helpful1901% 3.Neither helpful nor not helpful14179% 4.Helpful466930% 5.Very Helpful809552% 6.NA No Answer/No Opinion4133% Total/Approval %15,57494% 12

Collaborative Documentation Pilot- Client Survey Results 4.On a scale of 1 to 3, in the future, would you want your provider to continue to review your note with you? Percent Total Total % 1.No7856% 2.Unsure159511% 3.Yes % 4.NA No Answer/No Opinion7736% Total/Approval %13,88294% 13

Quality of Work Life ◦ Collaborative documentation eliminates: ◦ Documentation treadmill (always catching up) ◦ Hoping for No-shows to complete late paperwork ◦ Separation of paper process from clinical process 14

For More information on Collaborative Documentation Contact: Amanda Contact   Phone: (562)

BECOMING TRAUMA INFORMED 16

What is TIC ◦ Trauma informed care is an organizational structure and treatment framework that involves understanding, recognizing and responding to the effects of all types of trauma. 17

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The Impact of Trauma  Trauma is pervasive  The impact of trauma is very broad and touches many life domains  Trauma preys among the more vulnerable among us  Trauma affects the way people approach potentially helpful relationships 19

The Impact of Trauma (cont.)  Trauma has often occurred in the service context itself  Trauma affects staff members as well as consumers in human services programs 20

More About TIC  There are 7 domains (see handout in classroom) ◦ Domain 1 - Using “TIC-approved” tools ◦ Domain 2 – Client-driven care and services ◦ Domain 3 – TIC Educated and Responsive Team ◦ Domain 4 – Provision of TIC, EBP’s and best practices ◦ Domain 5 – Safe and secure environment ◦ Domain 6 – Community Outreach and partnerships ◦ Domain 7 – Ongoing improvement and evaluation  To learn more, please check out our Relias classes! 21

Polling Questions 1)In your organization, the initial (first encounter with the agency) intake, assessment and documentation process includes questions designed to sensitively and respectfully explore prior (including early childhood) and current trauma experiences at their own pace and in their own way. 1= YES 2= NO 2)Exploration of trauma related experiences is done with a calm, safe, secure, and supportive setting by caring, interested, and skilled practitioner; it is never confrontational, coercive and demanding 1= YES 2= NO Proprietary and Confidential22

QI “Monitoring” for TIC Principles How do we measure and monitor for the following? ◦ Domain 1 - Using “TIC-approved” tools ◦ Domain 2 – Client-driven care and services ◦ Domain 3 – TIC Educated and Responsive Team ◦ Domain 4 – Provision of TIC, EBP’s and best practices ◦ Domain 5 – Safe and secure environment ◦ Domain 6 – Community Outreach and partnerships ◦ Domain 7 – Ongoing improvement and evaluation 23