1. An Approach to The Use of Templates

2. Introduction and Purpose
The State expects the following:
“Treatment planning is to be personalized to the individual’s unique treatment needs.”
WAC B-0320
This presentation is to address how Providers make use of standardized formats (“templates”) when requesting services and developing a Treatment Plan.
Presentation is also based on 2016 findings around how service authorization requests and Treatment Plans have become “cookie cutter” and non- individualized.
To reinforce the importance of Client Voice to ensure individualization and continuity of documentation (“following the Golden Thread”)

3. An Example of Non-Individualized Language :
The following Template is often used in Auth. requests when documenting the reason why a level is being requested: "Intensification of addiction or mental health symptoms indicate a high likelihood of relapse or continued use or continued problems without close monitoring and support several times a week"

4. Another Example …
Substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have caused or exacerbated by substance use. Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home. Increase tolerance-A need for markedly increased amounts of substance to achieve intoxication or desired effects. Withdrawals from substance-anxiety. Cravings, or strong desire or urge to use the substance. Recurrent substance use in situations in which it is physically hazardous.

5. ASAM and Access to Care
Templates can be useful tools, but are only acceptable when:
The information in the template is personalized to the individual consumer
The information clearly identifies the issue(s), with specific examples that relate to the individual, and identify client’s symptoms from DSM-5
They are not using the term “and /or” (it is not conducive to individualizing a treatment plan)

6. Why is This Not Client-Specific ?
While templates can help structure notes, they don’t provide specific information about the client, such as:
Specific needs or behaviors that lead to them seeking services
Individualized, client centered, information that will be used when creating a treatment plan

7. So how can the Template become Client Focused?
One approach is to follow the Template with the statement “as manifested by”
Intensification of addiction or mental health symptoms indicate a high likelihood of relapse or continued use or continued problems without close monitoring and support several times a week as manifested by the client has been hospitalized on 3 previous occasions as a result of psychotic episodes, with the most recent episode last week (include specific dates), when he tested positive for stimulant; methamphetamine. Client reported no periods of abstinence, only periodic stays of active use when he was unable to access his drug of choice.

8. Forming a Treatment Plan
The “as manifested by” statement is also helpful when identifying client-specific areas of need that will be addressed in the opening treatment plan.

9. Forming a Treatment Plan
For instance:
For stabilization, do they meet criteria to remain in Level 1 or 2.1, or should they admit to a residential program?
Document attempts to engage and stabilize at a lower level before sending out to residential. Referrals to residential before completing Withdrawal Management extends residential stay and negates the first week or longer in the residential facility.
Specifies point of entry
Progress, or lack thereof, is now measurable through documentation after identifying the client’s baseline when treatment started.

10. Increasing the use of the “Client Voice”
During the 2016 reviews, it was noted that the majority of documentation was from the Counselor perspective (…Client needs to stay sober so he can get his life back…)
Instead, GCBH and the State encourage documentation that uses the Client’s Voice (own words):
Fred Flintstone expressed his desire to stop using methamphetamine, but feels defeated in his previous efforts. “I just want to get my life back. I don’t like getting locked up in the mental hospital. Every time I try I screw it up and start using again.”
What does Fred want?
What is he willing to do today?

11. Another Example of “cookie Cutter” use is when describing Access to care…
“Substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have caused or exacerbated by substance use. Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home. Increase tolerance-A need for markedly increased amounts of substance to achieve intoxication or desired effects. Withdrawals from substance-anxiety. Cravings, or strong desire or urge to use the substance. Recurrent substance use in situations in which it is physically hazardous”.

12. Access to Care Restating the DSM-5 Criteria is acceptable when:
Individualized examples link to client information, underscoring the reason client is seeking SUD services
The criteria help identify an appropriate treatment plan, specific to the client’s needs, as identified in the assessment
It supports the documentation in Dimension 4 and identifies client readiness to change (such as that they are self referred)

13. As manifested by:
Recurrent substance use in situations in which it is physically hazardous as manifested by the fact that the Client reported that his doctor has advised him to seek help to stop drinking because he has Hep C, but he hasn’t stopped drinking a 12 pack of beer a day…
Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home as manifested by the client saying, “I can’t keep a job to save my life…and now my wife and kids are living somewhere else and don’t want me around…”

14. Access to Care also requires an ASAM Dimensional assessment that is also individualized
Problem: Dimension II
Treatment Plan:
Client ignores medical needs as a result of continued active substance use, placing them at risk for ongoing medical complications (He has Hep C, but he hasn’t stopped drinking a 12 pack of beer per day)
Refer client to PCP to schedule a full medical screening to determine medical needs
Target Date: 2/2/17
Completion Date: 2/20/17

15. Another Example of needing to individualize the dimensional analysis and treatment plan
Problem: Dimension II
Treatment Plan:
Client does not have PCP
Provide client a list of medical facilities that accept Medicaid.
Assist with making contact to schedule appointment as part of the next individual session.
Target date: 1/30/17
Completion Date: 1/30/17.

16. Documentation to Support Authorization
Linking client voice to treatment plan

17. Another example of an authorization request in counselor voice
“Cx is vulnerable to relapse due to family history, mental health, and unhealthy relationships. Client has issues with lack of boundaries. Client has 3 children in her care and 4 in the care of other family members. Her use has led to multiple incarcerations, and is currently under the FOSA program. Client needs monitoring and structure while she develops self motivating strategies to move to Action/ Maintenance stage of change. Client needs to develop relapse prevention and community sober support to increase her chances of recovery success.”

18. Counselor voice Vs. Client voice
The previous statement identifies problems or challenges to the client’s recovery and provides information to support ACS linking to DSM-5, but remains in counselor voice advising what client needs, as opposed to what the client wants regarding their recovery.
This supports agency needs but does little to support where the client is in Dimension 4.

19. Instead…client voice should be used
Wilma says she relapses because, “Everyone in my family drinks and they are all really sick in the head.”
She also says that she isn’t able to stay by herself and therefore lets men stay with her and then, “I end up beaten up.”
Wilma also says, “I really need someone to help keep me from using until I can do it on my own. Isn’t there somewhere I can live where the people are like me and want to get clean?”

20. Additional Improvements to consider
Change “needs” to “wants” if client expresses they want to develop a strategy for monitoring or developing relapse prevention.
Use the person’s name
Check with client as to what they have done in the past that worked for them, avoid what didn’t work, and focus on the strengths they have developed in their previous programs.
Example: Betty stated that going to a family group during her last treatment program was helpful. Her mom and dad now understand the difficulties in quitting drugs.

21. Use Problem / Challenge statement:
History of past treatment attempts and past diagnoses of substance dependence have had short term success. Client reported, “This is my third time completing residential treatment but I just can’t stay clean.”
Client reported he / she has never completed an outpatient program, resulting in numerous relapses with minimal sobriety. Client reported, “I can stay clean for a while. I think about 1-2 months is the most time I have stayed clean, then my friends come around and I just can’t say no.”

22. So, what is the golden thread?
It is a metaphor for connecting client needs, assessments, and history to treatment and treatment planning.
Services are delivered based on what is “discovered” initially and then everything subsequently flows together…everything that involves the person is intertwined both in documentation and in what they say about their own treatment.

23. Attestation of Training Approach to the use of Templates
I have reviewed the GCBH template training materials and understand the information.
Signature: ____________________________
Print Name: ____________________________
Date: ________________________________
Please print, complete, and return this form to your manager for auditing purposes. You should also keep a copy for your own records.