1. Rocky Mountain Tobacco Treatment Specialist Certification (RMTTS-C) Program

2. Module 7: Treatment Planning Training Notes:
In this module, we will discuss how to complete a collaborative treatment plan.

3. Module 7: Treatment Planning Objectives
Learn to plan individualized treatments that match information gathered through the assessment interview
Demonstrate ability to complete a collaborative treatment plan using evidence-based strategies
Describe and demonstrate an understanding of the referral process
Training Notes:
This module provides additional information on:
Treatment plan goals
SMART goals
RMTTS-C Treatment Plan Form

4. Treatment Planning Training Notes:
Once the assessment interview is complete, treatment planning is the next step to provide comprehensive, quality healthcare to individuals who want to stop using tobacco.
The treatment plan is a written document that outlines the course and progress of treatment. It should be revisited and updated every time an individual comes to treatment. The treatment plan should be considered a “living document,” to be fine-tuned on a regular basis to meet an individual’s changing needs.
The treatment plan should follow seamlessly from the intake assessment. The treatment plan is the roadmap generated from the information obtained in the assessment.

5. Treatment Plan Goals Three main goals for a treatment plan:
Translate presenting problems into goals
Identify the actions necessary to achieve these goals
Set a date for when these goals will be met
Training Notes:
Review the three main goals of a treatment plan.
The first step is to translate presenting problems into goals. During the intake, TTSs identify specific problems, needs, and wishes of the individual. Reviewing what the individual has stated that they want is a good starting place for the goal-setting process. Whether a person wants to stop using tobacco, to cut down their tobacco use, or to simply learn more about tobacco cessation, it is important to create a main goal that matches their current motivation, skills and ability with the understanding that this will shift and change over the course of treatment.
It is important to note that often individuals will indicate higher levels of readiness to change than is true. Be aware of this tendency and listen for the “subtext” of their statements, which can provide more accurate information. An example of this is when a person states they are ready to stop their tobacco use but can only think of the difficulties and barriers to stopping.
Once a main goal is set, TTSs assist the individual to create a set of smaller, more manageable subgoals and specific actions that will help them to achieve the greater goal. Actions are “assigned” by the individual and TTS, working in collaboration but focused on what the individual wants in terms of interventions and behaviors to achieve the stated objectives.
When subgoals have been identified, it is important to set dates for when these goals will be met. If there is any uncertainty about the individual’s ability to follow through with the set goals, it is time to adjust the goals so they feel achievable for them.
Ensure that the identified goal is challenging but achievable. Goals that feel out of reach can decrease motivation.

6. Treatment Plan Basics Components of a successful treatment plan:
Process directed by the individual
Set SMART Goals
Attach dates to goals and follow up
Evidence-based strategies
Document referrals
Training Notes:
It is up to the individual and not the TTS to direct the process of treatment planning—TTSs can assist with goal-setting, but if the individual is not invested, change will not occur.
A key to successful treatment planning is setting SMART (Specific, Measurable, Attainable, Realistic, Timely) goals.
It is useful to attach dates to each goal and follow up on these dates. The follow-up assists with accountability.
Become familiar with evidence-based treatments for tobacco cessation (they will be covered in this training). Individuals will be more successful at achieving their goals if interventions are adjusted to match the individual’s needs based on level of addiction, ability, motivation and personal goals.
Finally, remember that if a referral or consult is created, it is important to document this on the treatment plan. This allows insurance companies, other healthcare providers and the individual to clearly see the course of treatment and the recommendations of the TTS.
This information will be discussed in detail over the next several slides.

7. Self-Directed Process
When the treatment planning process is directed by the individual, there is an increase in the individual’s investment and support for accountability.
Training Notes:
Often individuals may look to the TTS as the “expert” who will guide their process. However, this dynamic can limit an individual’s investment and accountability. Being “told” what to do versus “choosing” what to do are very different experiences.
Consider how it feels to be “told” to do something as compared to “deciding” to do something of your own free will.

8. SMART Goals Training Notes: Review SMART goals with trainees.
Specific – A specific goal provides information about what action will be taken and when it will be completed.
Measureable – A measureable goal provides information about what will be the measure of progress and how the individual will know when they have achieved their goal. Two effective ways to measure are intensity and duration. Intensity can be the amount of use or how many times per day the individual will engage in the behavior. Duration involves the amount of time the individual will have to meet the goal or how much time per day will be spent achieving the goal.
Attainable – An attainable goal is a goal that is perceived as challenging to an individual but is achievable. Goals that are set too high will decrease motivation. Often, individuals will decide that their first goal is to stop using tobacco completely on a certain date in the near future. Depending on the assessment of their readiness based on the information obtained in the assessment interview, the TTS may want to assist the individual in setting subgoals that can help to increase confidence and belief that they can be successful.
Realistic – A realistic goal is one that an individual has the knowledge, skills, resources and ability to achieve.
Timely – A timely goal is one that has a start and end date or a timeline when the goal will be accomplished.
A SMART goal is important because a goal that does not fit this criteria often does not facilitate successful completion of the goal and can be a setup for failure. It is also difficult to determine when a goal has been met if it is not outlined in SMART format.
Even SMART goals will not be helpful if they are not made by and for the individual who will take action to achieve the goal. It can be tempting, especially when working with tobacco cessation, to encourage individuals to set goals that meet the needs of the TTS, other healthcare providers, a broader system or family/friends. Tobacco cessation goals are more likely to be achieved if they match what the individual wants and is prepared to move towards.

9. SMART Goal Examples
Using the pack wrap my TTS provided me, I will note how I feel before I smoke each cigarette for the next week.
Before Friday, I will call my physician’s office and make an appointment to discuss my tobacco cessation medication options.
Training Notes:
Review these SMART goal examples. What makes these goals SMART goals?
Looking at the first example, we can see clearly that this goal matches the SMART goal criteria:
Specific – The goal specifies exactly how the task will be completed (i.e., using the provided pack wrap, completing the log before each cigarette, doing it for one week, etc.) and targets a specific area for improvement (i.e., identifying what feelings surround this individual’s decision to use tobacco).
Measurable – The goal states that the individual will note on the pack wrap how they feel before each cigarette. This creates a tangible document that can be referenced and measured.
Attainable – This is dependent upon the individual’s abilities, so it should be discussed with the client. But given the small time commitment (only a brief note about how they feel) and the small duration (one week) and given that they know how to use the tool provided, this goal feels attainable.
Realistic – The individual has been provided the resources they need to complete it – they have the pack wrap and have been instructed on how to use it and when. This ensures that the goal is realistic and achievable with the resources available.
Timely – The goal states that the individual will do this for one week. The individual and TTS will know at the end of that week whether the goal has been achieved.
By Wednesday, I will write down my quit date and share this information with my family and friends as well as post it on my refrigerator.

10. Setting Dates & Follow-up
Use the information from the assessment interview to guide:
Timelines
Start and end dates for goals
Follow-up meetings with TTS
Training Notes:
Consider setting timelines that provide enough time to take steps towards goals but are not too distant. If a person is going to take action towards their goal(s), it will happen sooner than later. Completion dates that are set too far out will usually be forgotten or disregarded. A key strategy is to set dates and goals that match an individual’s readiness to change.
After the completion of the assessment interview and implementation of the treatment plan, a follow-up meeting for individuals ready to stop their tobacco use is helpful to assess progress towards goals, explore supports and remove barriers to action.

11. Evidence-Based Strategies
Clinical Practice Guideline recommendations for best practices:
Cognitive and behavioral interventions with highest abstinence rates
Skills-building/problem-solving
Support and encouragement
NRT and tobacco cessation medications
Training Notes:
Review the Public Health Service Clinical Practice Guideline recommendations for tobacco cessation strategies. According to the Guideline’s recommendations (Fiore et al., 2008), the cognitive and behavioral interventions with the highest abstinence rates are:
Skills-building/problem-solving
Support and encouragement
These cognitive and behavioral interventions used in combination with nicotine replacement therapy (NRT) and/or other tobacco cessation medications are considered the best practice for tobacco cessation.

12. Consultation
There are many different situations in which you may consider consultation. Some examples include:
Primary care provider and/or psychiatrist
Substance abuse counselor
Individual and/or group counselors
Training Notes:
During treatment planning, it may become clear that consultation with other healthcare providers may be needed. This can be useful to obtain information, coordinate care, and communicate your patient’s tobacco cessation goals and plan.
© 2014 BHWP

13. Referrals
Provide contact information for referral site
Obtain release of information
Set a timeline
Offer “warm hand-off”
Document referrals
Referral follow-up
Training Notes:
There are several steps to providing successful referrals. During the intake assessment, information regarding consultation or referral may have been provided.
If you plan to contact a referral source, a release of information should be obtained from the client.
Mutually agree upon a timeline for contacting provider.
To facilitate follow through, it is helpful to provide a “warm hand-off” in which the TTS assists with making an introduction or telephone contact with the referral site.
As stated before, it is important to document the referral on the treatment plan. This allows insurance companies, other healthcare providers and the individual to clearly see the course of treatment and the recommendations of the TTS.
As with follow-up on goals, follow-up on referrals can increase the likelihood of a successful referral. Ask the individual directly whether they have followed through on the referrals provided. If the person has not yet followed up, the gentle reminder may encourage them to take action.

14. Treatment Plan Form Training Notes:
The next several slides will review the components of the RMTTS-C Program Treatment Plan Form. This is just one example of a treatment plan. The information in the form will be examined in detail as well as the importance and reasoning for inclusion on the form.

15. Treatment Plan Form Bill Smith November 2, 2016
Current tobacco use of one pack/day
Using the pack wrap my TTS provided me, I will note how I feel before I smoke each cigarette for the next week.
Training Notes:
The treatment plan begins with gathering some basic information about the individual. Fill out the top portion of the form with the person’s name and the date the treatment plan is being completed.
Under presenting problem, write down the individual’s problem statement. As we discussed earlier, a problem statement is a brief description of a condition and must be specific. The problem statement should only be one sentence long and only describe one problem.
Although only one is shown here, there is space to list three different goals on the treatment plan form. Feel free to use one or all spaces provided, there is no need to fill in all of the empty spaces. Additional space was provided to meet the varied needs of different individuals. Of course, it is essential that the treatment goal listed meets the SMART goal criteria. Underneath the treatment goal, list the action(s) the individual indicates are necessary to achieve the goal. Finally, fill in the date of completion for each goal.
Make 7 copies of the pack wrap form
Keep pack wrap form in cigarette packs
Keep a pencil/pen handy to record feelings before each cigarette

16. Treatment Plan Form Dr. Mary Jones 303.279.1646 Mary.M.Jones@uch.org
Primary care physician
Ed Monroe
Substance abuse counselor
Training Notes:
There are situations in which a consultation with the individual’s other healthcare providers may be needed. Examples of different providers are primary care physicians, psychiatrists, psychotherapist/counselor, among others.
If a consultation is necessary, write down the contact information in the space provided, including name, phone and . Indicate the relationship to the individual with whom you are working and the date the consultation is completed.
Depending upon the process your agency requires, a separate note may be needed to document the completion of the consultation and the content of the conversation.
Consultation with different treatment providers will ensure a consistent, cohesive and comprehensive tobacco cessation strategy. Often individuals may receive conflicting information regarding tobacco cessation if consultation does not occur.

17. Treatment Plan Form Colorado Quitline Tobacco free group
November 16, 2016
Training Notes:
Depending upon the resources available at your agency, it may be necessary to provide individuals with referrals to other services, treatment providers and resources. Examples of outside resources include the quitline, tobacco cessation groups, Nicotine Anonymous, among others.
Ask trainees to share examples of resources in their city/state that they refer individuals to.
Under “Follow-up,” fill in the date of your next appointment or scheduled contact.
At the bottom of the treatment plan, the individual should print their name, sign and date the document to enhance commitment and accountability. The TTS should sign and date the document as well.

18. Practice Session Treatment Planning Training Notes:
Use the vignette to complete the treatment plan form. Perform this exercise as a large group, discussing how trainees would fill out each section.
Randall is a 52-year-old widowed Native American male of the Navajo Nation. He has a 39-year smoking history; he began smoking at age 13 because all of his friends smoked tobacco. He currently smokes his first cigarette of the day immediately upon waking. Randall lives with his eldest daughter, her husband and two children on the reservation in northwestern New Mexico. Randall has tried to quit several times and was able to quit the last time for six months. He lived tobacco-free until his wife’s death two years ago. He says that the stress of her death caused him to begin smoking again. Randall used Bupropion and nicotine gum throughout his quit. Prior to that, Randall reports having quit “cold turkey” a few times, but these attempts lasted only a few days each. During each quit attempt, Randall continued to use Navajo Mountain Tobacco which is gathered locally and used during traditional ceremonies. This spiritual use of tobacco discourages inhaling. He is proud of the fact that he was able to manage urges to smoke commercial cigarettes when partaking in sacred ceremonies the last time he quit and attributes it to the effect of the medication. Randall’s motivation to quit involves getting to spend more time with his grandchildren. He reports that they have been asking him to quit and that their mother complains frequently that the children smell of cigarette smoke when they spend time with him. He hopes that if he quits, it will improve family harmony. He reports no behavioral health conditions, but does admit to drinking “three or four beers” daily. He denies any substance abuse. Randall was referred to a TTS at the local wellness center because he was recently diagnosed by his physician with early stage emphysema. He is seeking help with quitting smoking due to concerns about his health and out of respect for his daughter’s wishes. His current CO level is 34.

19. Treatment Planning Discussion Training Notes:
Allow 5-10 minutes for discussion.