Treatment Planning and ReAssessment to Enhance Mental Health

Treatment Planning and ReAssessment to Enhance Mental Health with Dr. Dawn-Elise Snipes

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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.


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?
 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,
 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?

Summary
 A good assessment and integrative summary forms the foundation of an effective treatment plan. When clients participate, they are empowered and more motivated. Reassessment activities help the client see progress, get support and make adjustments to promote rapid cycle change

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