1. PSR Individualized Treatment Plan PSR Individualized Treatment Plan April-May 2005

2. PSR Services 16.03.09.453 The goal of PSR services is to aid participants in work, school, family, community or other issues related to their mental illness. It is also to aid them in obtaining developmentally appropriate skills for living independently and to prevent movement to a more restrictive living situation. All services provided must be clinically appropriate in content, service location and duration and based on measurable and behaviorally specific and achievable goals.

3. PSR Services Written Individualized Treatment Plan IDAPA 16.03.09.453.02 Services must support the goals of PSR which are maximum reduction of mental disability and achievement of the highest possible functioning level for that participant. For adults this means becoming independent or maintaining the highest level of independence. For children this means learning or maintaining developmentally appropriate role functioning.

4. PSR Services Written Individualized Treatment Plan The individualized treatment plan identifies the issues, goals, areas of need, objectives and the total number of hours and types of services estimated to achieve all objectives based on the ability of the participant to effectively utilize services. The individualized treatment plan must be developed by the participant, family, other support systems and the provider agency. Must be documented by the provider agency.

5. PSR Services Written Individualized Treatment Plan Must include the following: –An issue statement specifically describing the participant's behavior that directly relates to the mental illness and functional impairment that was identified in the assessment –A statement which describes the participant's goals relative to the goals of PSR

6. PSR Services Written Individualized Treatment Plan Must include the following: –Overall goals and concrete, measurable objectives to be achieved, including time frames for completion. –At least one objective is required for the focus areas which will most likely lead to the greatest stabilizing impact. –This should include at least one objective in each of the two focus areas which qualify the participant for PSR.

7. PSR Services Written Individualized Treatment Plan Must include the following: –Tasks that are specific, time limited activities and interventions designed to accomplish the objectives in the plan and are developed by the participant and the provider. –Each task description must specify the anticipated place of service, the frequency of services, the types of service and the person responsible to assist the participant in the completion of tasks.

8. PSR Services Written Individualized Treatment Plan Must include the following: –Documentation of who participated in the development of the individualized treatment plan. –The participant must take part in the development of the plan. –The adult participant or guardian must sign the plan or documentation must be provided why this was not possible, including refusal to sign.

9. PSR Services Written Individualized Treatment Plan Must include the following: –For a minor child participant, the parent or legal guardian must sign the plan. –A copy of the plan must be given to the adult participant and the guardian or to the parent or legal guardian of the child.

10. PSR Services Written Individualized Treatment Plan The individualized treatment plan must be developed within 30 calendar days from the initial face to face contact between the provider agency staff and the participant, or the parent or legal guardian of a minor child.

11. PSR Services Written Individualized Treatment Plan An individualized treatment plan review by the provider agency staff and the participant must occur at least annually. –During the review, the staff and participant review any objectives which may be added or deleted from the plan. –Input from other participants in the plan including service providers must be considered. –Other attendees of the review may be chosen by the participant/parent/guardian and the agency staff.

12. PSR Services Written Individualized Treatment Plan Must be reviewed and signed by a physician or licensed practitioner of the healing arts at least annually indicating services are medically necessary. (licensed physician, physician assistant or nurse practitioner and clinical nurse specialist with experience prescribing psychotropic medication)

13. PSR Services Written Individualized Treatment Plan Once the date of a plan is established ( physician signature date unless past due), that date continues to be the annual date of the plan. Any subsequent plans must be received by the MHA on or before the expiration date of the plan. If a subsequent plan is not received on or before the expiration date of the current plan, services that are provided in the interim will not be reimbursed.

14. PSR Services Written Individualized Treatment Plan The eligible participant will be allowed to choose whether or not he desires to receive PSR services and who the providers of services will be to assist in accomplishing the objectives stated in the plan. Documentation must be included in the participant's file showing that the participant has been informed of his rights to refuse services and choose providers.

15. Individualized Treatment Plan Authorization Requirements Required documentation (16.03.09.451.03): –Participant demographic information –Comprehensive assessment –Written individualized treatment plan –Adult services- rehabilitation outcome data (MH Profile Form) –Children's services- CAFAS/PECFAS

16. Changes in Plan Hours or Service Type Must be approved by the MHA. A clear rationale for the change in hours or service type must be included with the request.

17. Changes to Plan Objectives 451.06 Include recommendation and rationale in the next 120 day review. Substantial changes requiring immediate changes in the plan need to be submitted to the MHA for approval. The request must include the recommendation and rationale for the change.

18. Minor Changes to Individualized Treatment Plan Tasks 451.07 Submit amended plan to the MHA detailing the necessary and specific changes to the plan so long as there is no change in hours or types of services. If no response received from the MHA after 10 working days proceed to incorporate those specific changes.

19. PSR Services Written Individualized Treatment Plan PSR services that must be specifically identified on the Individualized Treatment Plan –Pharmacological Management –Individual PSR –Group PSR –Collateral Contact –Nursing Service –Psychotherapy –Occupational Therapy

20. PSR Individualized Treatment Plan Client Name Social Security Number Healthy Connection Physician Medicaid Number Healthy Connections Number CAFAS Score- Children only Provider Agency Completing the Plan

21. PSR Individualized Treatment Plan Date of Amendment- when applicable Amendment comments- Justification and description of what is being amended in the plan

22. PSR Individualized Treatment Plan Date of Plan- date of physician signature 120 Day Review- 120 days from plan date 240 Day Review- date due from plan date Annual Update- date annual update needs to be completed, submitted and authorized by (ongoing date of the plan)

23. PSR Individualized Treatment Plan Diagnostic Summary- Indicate Primary Diagnosis with (P) –Axis I: Clinical Disorders, Other Disorders That May Be a Focus of Clinical Attention –Axis II: Personality Disorders, Mental Retardation –Axis III: General Medical Conditions –Axis IV: Psychosocial and Environmental Problems –Axis V: Global Assessment of Functioning (GAF) scores for both current and highest past GAF

24. PSR Individualized Treatment Plan Duration of Principal Diagnosis Select one –Less than one year –On to two years –More than two years

25. PSR Individualized Treatment Plan Functional Areas Identified as Deficits in the Assessment Must be documented and justified in the assessment –Health/Medical- Housing –Social Interpersonal - Family –Vocational/Educational - Community/Legal –Basic Living Skills - Financial

26. PSR Individualized Treatment Plan Functional Areas –Areas identified in the assessment to be addressed in the plan –Psychiatric –2 functional areas identified in the comprehensive assessment Health/Medical - Housing Social Interpersonal - Family Vocational/Educational - Community/Legal Basic Living Skills - Financial

27. Issues Issues- identified for each functional area Brief summary statement that specifically describes the participant's behavior that directly relates to the mental illness and functional impairment Should also describe their strengths

28. Goals If you don’t know where you are going, you will probably end up somewhere else. Lawrence J. Peter

29. Goals Broad general statements Express the participant's desires, what they want to change Written in their words Tied to discharge criteria

30. Goals Goals can reflect –Life goals –Service or treatment goals –Quality of life goals

31. Goals Directed towards recovery Responsive to need Strengths based Written in “I want to…” statements

32. Objectives Measurable, objective steps to accomplish the goal Short term, time limited with time frames for completion

33. Objectives Immediate focus of treatment but not a description of the intervention Focus on positive changes in behavior, improving functioning, attaining new skills not just decreasing symptoms or stopping a behavior Written in “The participant will…” statements Specify one change at a time

34. Objectives Reasonable Measurable Appropriate to the treatment setting Achievable Understandable to the participant

35. Objectives Time specific Written in behaviorally specific language Responsive to the participant’s needs and recovery goals Appropriate to the participant’s age, development and culture

36. Objectives At least one objective for every goal Keep the plan manageable

37. Tasks The services, interventions, and activities that will be provided by the treatment team Assist the participant achieve their goals and objectives

38. Tasks Describe the services to be delivered Specify –Who –What –Where –When- frequency, intensity, duration –Why

39. PSR Individualized Treatment Plan Expected End Date Dates may vary depending on the objectives and tasks needed to accomplish the goals

40. PSR Individualized Treatment Plan Type, Frequency & Hours Summarize totals by service code H2017 (RHIP) 1hr/1x/wk 52 hrs/ yr

41. PSR Individualized Treatment Plan Signatures- must be hand written, with credential and date also hand written Participant/guardian PSR professional that wrote the plan Physician Others involved in the plan development

42. PSR Individualized Treatment Plan Service Plan Authorization Form –Provider/Region –Client Name –Provider Number –Agency Phone Number –Agency FAX Number

43. References Treatment Planning for Person Centered Care: The Road to Mental Health and Addiction Recovery Neal Adams and Diane M. Grieder Elsevier Academic Press 2005