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Treatment Planning and Clinical Pathways

Treatment Planning and Clinical Pathways. Presented by Lorain County Alcohol and Drug Abuse Services. Agenda. Treatment Planning Introduction and Overview Treatment Plan Requirements Introduction to Clinical Pathways Model Treatment Planning Exercise.

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Treatment Planning and Clinical Pathways

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  1. Treatment Planningand Clinical Pathways Presented by Lorain County Alcohol and Drug Abuse Services

  2. Agenda • Treatment Planning Introduction and Overview • Treatment Plan Requirements • Introduction to Clinical Pathways Model • Treatment Planning Exercise

  3. THERE ARE NO SHORTCUTS TO ANY PLACE WORTH GOING • Beverly Sills

  4. What separates a good Treatment Program from a mediocre one is the team’s ability to formulate and implement a series of moves and approaches capable of producing sustainable improvement in the client.

  5. Guiding Principles/Premises • Treatment Planning is a Science not an Art • Tx Planning is the development of Strategies to address the clients conditions • Program Components that are routine may not be appropriate for the Tx Plan • Every client is different and moving a client from point A to Point B may require a different Stategy

  6. Guiding Premises (cont.) • Treatment Plans do not have to be long • Tx Plans are driven by the assessment • All current problems or conditions of this client must be addressed • Interventions must be timely • Interventions should be sequential or concurrent • Humans are resistant to change • The Course of Change is not always a straight Path

  7. Prochaska and DiClemente’s Stages of Change Model • Precontemplation • Contemplation • Preparation • Action • Maintenance

  8. Orienteering Model A B C D E

  9. Orienteering in Addiction Client in Denial Recognizes there might be a problem Accepts that he has an illness Accepts Recovery Has the skills to manage his illness Has stabilized other critical life areas / concerns and Personal Relapse Prevention Plan

  10. ODADAS Standards3793:2-1-06 • An Individualized Tx Plan shall be written for each client within seven days of completion of the assessment or at the time of the first face-to-face contact following the assessment.

  11. ODADAS Standards (cont) • ITPs shall be based on assessment and include, at a minimum: • Client Identification • Level of care to which client is admitted • Problems to be addressed • Measurable goals that address client’s needs • Measurable treatment objectives with time frames for achievement of each objective • Frequency, duration and types of treatment services • Original Signatures • Time frames for reviewing and updating

  12. JCAHO StandardsStandard AL.3 • For each patient there is a written comprehensive and individualzed description of the treatment to be undertaken. • The Tx Plan specifies the regular times at which the plan will be reassessed • Plan is based on problems and needs identified in the assessments • There is documented justification when identified clinical problems and needs are not addressed

  13. JCAHO (cont) • The patient’s perception of his needs are documented • The patient’s participation in the development of his Tx Plan is documented • Each patient is reassessed to determine current clinical problems, needs, and responses to treatment • The reassessment is conducted at regular times and when major clinical changes occur • Changes in treatment are documented

  14. Ohio Chemical Dependency Professionals Board • The Treatment Contract: • Is based on the assessment • Is a product of a negotiation between the client and counselor • The language of the problem, goal and strategy statements should be specific, intelligible to the client and expressed in behavioral terms • The problem statement concisely elaborates on a client need • The goal statements refer specifically to the identified problem and may include one or a set of objectives intended to resolve the problem • The goals must be expressed in behavioral terms • The plan or strategy is a specific activity that links the problem with the goal • It describes the services, who will provide them, where they will be provided and at what frequency • It must be regularly reviewed and modified as appropriate

  15. Review Common Requirements between Regulating Bodies • Review Treatment Plan Development Handout • Take a Break

  16. Clinical Pathways • Everything we do (from intake through discharge) is to prepare the client to be able to manage their illness and we want to know how effective we are at preparing them. • We need to ask: Did we do the right thing to the right person, at the right time and in the right amounts to impact the problem and sustain functionality? • Successful outcome is achieved when your client meets criteria for discharge and is able to maintain that level of functioning after that level of care has been terminated.

  17. Clinical Pathway • A Clinical Pathway is a sequence of clinical interventions designed to move a client from their current condition in all critical life areas to an improved condition or functional level in that area. • Clinical Pathways take into account the client’s condition, current level of functioning, assets, deficits and other obstacles that may affect the treatment episode.

  18. Continuum of Functioning Dysfunctional Functional Every critical life area is a continuum from total dysfunction to completely functional

  19. ODADAS CLINICAL PLACEMENT PROTOCOL FOR LEVEL OF CARE Dimension 1 Level of Intoxication and Withdrawal Potential Dimension 2 Biomedical Conditions and/or Complications Dimension 3 Emotional/Behavioral/Cognitive Conditions and/or Complications Dimension 4 Level of Treatment Acceptance or Resistance Dimension 5 Relapse Potential Dimension 6 Recovery Environment Critical Life Areas Living Arrangements Prior Addiction Treatment History Social Environment Legal Involvement Family History and Support Education Current or Prior Mental Health Employment Treatment or Conditions Victimization History and Issues Medical Status and Conditions

  20. Alcohol and Drug Abuse Alcohol and Drug Dependence Homelessness / Housing Relationship Issues Victimization Issues Employment Transportation Education Mental Health Issues Client Grief Reaction Anger Issues Criminal Thinking Medical Condition / Problems Treatment Areas

  21. Continuum of Functioning Dysfunctional Functional 1.Incompetence due to physical, emotional, or mental limitations

  22. Continuum of Functioning Dysfunctional Functional 2. Incompetence due to obstacles that present before the client that the client is not able to navigate

  23. Continuum of Functioning Dysfunctional Functional 3. Dysfunction due to obstacles that are navigatable or may be navigated with the addition of resources

  24. Continuum of Functioning Dysfunctional Functional 4. Partially functional, but requiring the addition of resources or training to be fully functional

  25. Continuum of Functioning Dysfunctional Functional 5. Fully functional requiring no additional service or resources

  26. Continuum of Functioning Dysfunctional Functional Once you have placed your client at the appropriate level of functioning through your assessment and ongoing assessments: • Establish a level of functioning that you and the client believe he/she can obtain (this may be movement up one or two levels). This is the treatment objective and graphed as the Level of Improved Functioning. • In the Pathways Model a set of Interventions has been prescribed to move a client from one level of functioning to another. These prescribed interventions are based on the collective thinking of six clinicians with over seventy years of experience in treatment---you may want to develop your own pathways. • The Interventions chosen must be negotiated and agreed upon with the client. You are the professional and may need to educate why certain interventions are important.

  27. Level of Improved Functioning Dysfunctional Functional Incompetence due to physical, emotional, or mental limitations Objective: stabilize condition and / or secure external resources to assist the client with the condition

  28. Level of Improved Functioning Dysfunctional Functional Incompetence due to obstacles that present before the client that he/she is not able to navigate. Objective: client to develop alternative solutions to address the issues or obstacles and / or teach the client how to navigate obstacles

  29. Level of Improved Functioning Dysfunctional Functional Dysfunction due to obstacles that the client can navigate or may be navigated with the addition of resources Objective: Client will become aware of issues that have prevented them from navigating the obstacle and / or how they can access additional resources

  30. Level of Improved Functioning Dysfunctional Functional Client is partially functional, but requiring the addition of resources or training to be fully functional Objective: Client will mobilize resources to become fully functional

  31. AOD DEPENDENCE • Client in denial and not motivated • Client motivated but lacks skills / supports • Client has skills and requires monitoring of his/her utilization of resources/skills • Client has been in recovery/treatment and yet continues to experience relapses Levels of Dysfunction

  32. ALCOHOL AND DRUG DEPENDENCE Levels of Functioning Levels of Dysfunction     Client in denial and not motivated. Client motivated but lacks skills/supports. Client has been taught skills and requires monitoring of his/her utilization of resources/skills. Client has been in recovery/ treatment and yet continues to experience relapses.

  33. Client in denial and not motivated The Client will understand their emotional / cognitive defenses: will move from denial to acceptance of their illness. AOD DEPENDENCE 1 Condition Objective

  34. Client motivated but lacks skills / supports The Client will develop behaviors / skills that will support their recovery. AOD DEPENDENCE 2 Condition Objective

  35. Client has been taught skills and requires monitoring of his/her utilization of resources/skills The Client will consistently practice behaviors / skills that indicate acceptance of recovery. AOD DEPENDENCE 3 Condition Objective

  36. AOD DEPENDENCE 4 • Condition: Client has been in recovery/treatment and yet continues to experience relapses • Objective: Client will have an understanding of what has contributed to relapses and developed a plan to prevent in the future. Client will demonstrate skills, behaviors, and attitudes necessary to implement the plan successfully.

  37. ALCOHOL AND DRUG DEPENDENCE Levels of Improved Functioning     Client will understand their emotional/ cognitive defenses: will move from denial to acceptance of their illness. Client will develop behaviors/skills that will support their recovery. Client will consistently practice behaviors/skills that indicate acceptance of recovery. Client will have an understanding of what has contributed to relapses and developed a plan to prevent in the future. Client will demonstrate skills, behaviors, and attitudes necessary to implement the plan successfully.

  38. The Client will understand their emotional / cognitive defenses: will move from denial to acceptance of their illness. CLINICAL PATHWAY AOD 1 • CNL will educate Client about the progressive patterns and effects of addiction through lectures and readings. • Client will be assigned to discuss consequences and feelings related to the circumstances that brought him/her into treatment in group, individual and/or family counseling. • Client will explore how his/her behaviors, attitudes, and life situations parallel what he/she has learned about the disease of addiction through self-exploratory assignments. (AOD History or 20 Harmful Consequences) • Client will present these assignments in group for feedback and approval by staff and peers. • CNL will prepare the Family for an Intervention.

  39. The Client will develop behaviors / skills that will support their recovery. CLINICAL PATHWAY AOD 2 • Client will explore in group how addiction was used to escape from stress, physical and emotional pain, and boredom and solicit suggestions from staff and peers. • Client will complete AA first-step worksheet and present to staff and peers for feedback and approval. • Client will be educated to 12-Step Recovery Principles. • Client will be assigned to attend 12-Step Meetings, get a Sponsor, and identify a Home Group. Client will process progress and issues with staff and peers. • Client will learn improved problem solving techniques, coping strategies, and communication skills through lecture, readings, role playing, and other behavior rehearsal sessions. • Client will be educated about relapse and relapse prevention.

  40. The Client will consistently practice behaviors / skills that indicate acceptance of recovery. CLINICAL PATHWAY AOD 3 • Client will develop a Relapse Prevention Plan and present to staff and peers for feedback and approval. • Client will develop a Recovery Plan and present to staff and peers for feedback and approval. • Client will be connected to any identified Community Support identified through Treatment Plan (GED/Vocational Prep, Mental Health Professional, Medical Professional, Housing Assistance, etc.) • Client will be admitted to Continuing Care Phase of Treatment. • Client will report level of compliance with Recovery Plan and any issues that are relapse risk to his/her CNL, Aftercare Group, and Sponsor on a weekly basis.

  41. Client will have an understanding of what has contributed to relapses and developed a plan to prevent in the future. Client will demonstrate skills, behaviors, and attitudes necessary to implement the plan successfully. CLINICAL PATHWAY AOD 4 • CNL will educate Client to Relapse and Relapse Prevention through lectures and readings. • Client will complete a Relapse History and Chronological History of Critical Incidents. • Client will complete a Coping Skills/Problem Solving Skills analysis. • CNL will work with Client to strengthen any deficits noted in Coping Skills/Problem Solving through teaching, coaching, strategizing. • Client will take Relapse History to group for feedback from staff and peers. • Client will develop a Relapse Prevention Plan based on staff and peers feedback to be approved by staff, peers, family, and sponsor. • Client will develop a Relapse Contract with CNL, family and sponsor.

  42. Your Assignment • Your team is assigned a Problem Area • Develop a Continuum of Dysfunction • Develop a Levels of Functioning Continuum • Develop a series of Interventions for the lowest and second highest level of functioning • Present to the other Participants

  43. UNEMPLOYMENT Levels of Functioning Levels of Dysfunction     Client is disabled and not employable at this time. Client lacks job skills and behaviors that permit him/her to maintain steady employment Client possesses job skills but is not satisfied with types of jobs he/she is trained to do. Client is unemployed, has job skills, and wants to enter the job market.

  44. UNEMPLOYMENT Levels of Improved Functioning     Client will be assessed for possible alternative employment or capabilities. Client will develop sufficient job skills to be eligible for employment and will develop behaviors that will support his/her maintaining employment. Client will develop career objectives and develop a plan to follow career path. Client will utilize appropriate resources to obtain employment. Client will obtain employment.

  45. Client will be assessed for possible alternative employment or capabilities. CLINICAL PATHWAY UNEMPLOYMENT 1 • CNL will refer Client to the Bureau of Vocational Rehabilitation for an employment evaluation. • CNL will contact BVR to coordinate AOD services with BVR services.

  46. Client will develop sufficient job skills to be eligible for employment and will develop behaviors that will support his/her maintaining employment. CLINICAL PATHWAY UNEMPLOYMENT 2 • CNL will refer Client to BVR or Department of Job and Family Services for Job Training. • CNL will contact Lorain County Department of Job and Family Services to coordinate services with DJFS caseworker. • Client will be assigned to identify current behaviors that sabotage his/her employment. • Client will develop a Relapse Prevention Plan for sabotaging behaviors and present to staff and peers for approval.

  47. Client will develop career objectives and develop a plan to follow career path. CLINICAL PATHWAY UNEMPLOYMENT 3 • Client will complete assignments designed to identify his/her ideal job. • Client will research careers that closely align with ideal job characteristics. • Client will be referred for aptitude testing through DJFS • Client will be referred for Career Counseling through Lorain County Community College or another Career placement service. • Client will present a plan for following career path and present to staff and peers for feedback.

  48. Client will utilize appropriate resources to obtain employment. Client will obtain employment. CLINICAL PATHWAY UNEMPLOYMENT 4 • Client will be referred to Lorain County Community College or other job placement service. • Counselor will coach client how to utilize newspaper and internet in job search. • Client will develop resume and present to staff and peers for feedback. • Client will practice interviewing skills with staff and peers.

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